This case study involves a 53-year-old African American man who presents with elevated blood pressure. Key findings include a loud S2, sustained PMI at the 5th intercostal space, and an S4 gallop. Additional tests show LVH by voltage on EKG and prediabetes based on fasting blood glucose and A1C. The summaries address the patient's diagnoses of hypertension and prediabetes, pharmacologic treatment plan starting ACE inhibitors/ARBs and metformin, and lifestyle modifications recommended.

1. Complex Patient Case Study Note
James Flemer

2. Patient Background Information and Assessment
Case Study Question:
A 53-year-old African American man is in for follow up of
his elevated blood pressure. He was seen last week in your
office for a Department of Transportation commercial driver’s
examination where his blood pressure was 176/92. Subjective
questioning is negative. BP today is 174/94.
His physical exam is remarkable for a loud S2, sustained PMI at
5icslmcl, an S4 gallop is present. The remainder of his physical
exam is unremarkable.
Family history is remarkable for high blood pressure.
Self describes his lifestyle as pretty sedentary due to driving
long hours every day. Diet is often fast food with many cups of
coffee.
· EKG – NSR with LVH by voltage
· CBC – normal
· CBP – normal except for glucose 154 (fasting). Fingerstick
last week was 152
· A1C – 7.8
1. List five subjective questions. It would be very important to
know about this patient.

3. 2. Explain the significance of the loud S2 finding.
3. What does the finding of his PMI indicate?
4. Explain the significance of the PMI in the normal location.
5. Explain the significance of the S4 finding.
6. Explain the finding of LVH, given his current circumstances.
7. What additional diagnostics or testing (if any) you would like
to order?
8. What are the top two diagnoses you are going to address at
this time?
9. What is your pharmacologic plan for this man? Why did you
choose the agent you did? Be sure to state your rationale and
references.
10. Identify 5 lifestyle modifications to improve his health that
he could implement in his current situation.
S Question 2
O Question 1, 4
A Question 3
P Question 5, 6
Question 1 – Subjective Questions
The purpose of this paper is to review the patient’s chart and
answer the questions above. Below are the five subjective
essential questions I would ask the patient in order for me to
fully carry out my assessment and diagnoses of his conditions:
1. Do you have a family history of hypertension or diabetes?
Hypertension and diabetes tend to run in the family due to
different gene mutations (Gabb et al., 2016).
2. Do you currently take any medication for high blood
pressure, both prescribed and/or non-prescribed? (some patients
already have a diagnose of hypertension but do not follow their
treatment. Taking blood pressure medication inadequately could
create a rebound effect (Challa et al.,2020).
3. Do you experience any abnormality in your breathing? Do
you feel a pounding sensation with your pulses? Especially in
your neck vein? And have you been diagnosed with any
Coronary Artery Diseases in the past? This question is asked to

4. assess the adverse effect of his conditions that could potentially
make him a higher risk for other serious and urgent issues like
myocardial infarction, hypertensive retinopathy, and
cerebrovascular accidents; for example, the presence of
pheochromocytoma can increase the secretion of
catecholamines, which will lead to a higher level of blood
pressure (Hu et al., 2015)
4. What is your current diet plan like? (saturated food
consumption will increase blood pressure, and inadequate
consumption of sugar and coffee can raise the blood glucose
level in patients with diabetes.
5. Do you have any other stress factor in your life that could be
possibly affecting your health status both physically and
mentally?
It is crucial to accurately diagnose the patient. A nurse
practitioner cannot conduct a thorough assessment without
gathering historical data, especially from the patient
themselves. Those data, in addition to the clinician clinical
background, will allow the nurse practitioner to do a full and
accurate diagnose of their condition (Volpe et al., 2019)
Question 2 – Loud S2 Finding
The S2 sound is an auditory second heartbeat that tends to be
brief and has two basic elements. One of the elements is
characterized by the closure of the aortic valve observed as A2,
and the other elements is characterized by the closure of the
pulmonic valve (P2). S2 is also characterized as the closure of
the aortic valve to signify the pressure in the left side of the
patient’s heart. Therefore, a louder and lengthy S2 sounds can
signify a severe hypertensive state. Given the patient's objective
information, it is appropriate to suspect the loud S2 finding is
due to hypertension (Dornbush, Turnquest, 2019)
Question 3 – Point of Maximal Impulse (PMI Indication)
The point of maximal impulse is defined as the point where a
maximal impulse can be felt against the chest wall. Most
frequently, this is felt from the apex or at the tip of the heart. A

5. normal point of maximal can be normally located towards the
mid-clavicular point at intercostal space 5 (Aronow, 2017).
There should be no other impulses felt at the other location
apart from the apical region. The normal finding should be non-
sustained tapping, and it is normally not larger than 2-3cm in
diameter. On the other hand, Abnormal finding of PMI, which is
usually sustained and forceful outward movement is prolonged
throughout systole, would be an indication of a ventricle doing
pressure and harder work normally seen with left ventricular
hypertrophy or states of outflow block causing the heart to
pump harder, e.g., high blood pressure. Especially In this
scenario mentioned above. High pressure can affect the left
ventricle secondary to the increased workload, which will
eventually increase the size and thickness of the chamber. In the
given case study, the patient most likely had uncontrolled high
blood pressure, which prompted modifications at the pressure
and level of this heart. (Amin, Siddiqui,2019)
Question 4- PMI in the Normal Location
A normal point of maximal can be located towards the mid-
clavicular point at intercostal space 5. There should be no other
impulses felt at the other location apart from the apical region.
The normal finding should be non-sustained tapping, and it is
normally not larger than 2-3cm in diameter. About 75% of
people will have palpable PMI. Therefore, it is crucial to
determine if the patient has any displacements of this normal
impulse beat. Any abnormal location or displacement can be an
indication of a variety of heart conditions (Amin,
Siddiqui,2019)
Question 5- S4 significance Finding
The S4 heart sound (S4) is characterized as an abnormal delayed
or late diastolic sound caused by a forcible atrial contraction in
the occurrence of decreased ventricular compliance. S4 heart
sound occurs from the pumped blood thumping into the left

6. ventricle from the atria. S4 may signify diastolic heart failure
that happens when the left ventricular hypertrophy becomes
severe. Clinicians can notify the finding on the ECG located
between the P wave endpoint and the beginning of the Q wave.
According to (Gabb et al., 2016), When an S4 heart sound is
heard at the level of the left ventricle, this is due to systemic
hypertension, coronary artery pathology, or aortic stenosis.
(Liu, Wu, Ma,2018)
Question 6- Explanation of Left Ventricular Hypertrophy (LVH
Findings)
The LVH discoveries finding is an indication that the cardiac
muscles have thickened, causing hypertension in a person, as
seen in the patient above. LVH placed the patient at very high
risk for complicated issues like heart failure or high blood
pressure. The left ventricle is in direct contact with the systemic
circulation through the aorta. And because of that, the high
pressure eventually creates a resistance effect on the LV, whi ch
needs to increase its capacity in order to be able to sustain the
pump function of the heart. Condition like this is categorized to
be a compensatory mechanism usually seen in the case of
patients with prolonged high values of blood pressure.
(Aronow,2017)
Question 7-Additional Testing and Diagnostics
There are numerous testing that should be done on the patient
based on his condition; I would order various tests to monitor
and assess his pathologies condition, especially his
cardiovascular status, which could indicate that the patient has a
higher risk of complications.
These are the following testing’s I would initiate based on the
rationale attached to it:
· Echocardiography – is one of the accurate testings to
determine the patient's cardiovascular value and output,
especially of the left ventricle. The rationale for doing this
testing is to consider when the mass index of the ventricle is
over 125 g/m2 in men and over 110 g/m2 in women.

7. · Glycated hemoglobin (A1C) test. This lab work indicates the
patient’s average blood sugar level for the past three months.
The blood work measures the percentage of blood sugar in the
oxygen-carrying protein in red blood cells (hemoglobin). The
higher the patient’s blood sugar levels, the higher the
hemoglobin level. If the patient’s A1C level is higher on two
separate tests, that would indicate a sign of diabetes. Normal
AIC level is
· Lipid panel profile (which includes the LDL, HDL, VLDL,
and Triglycerides) - these blood work based on the results could
be indicative of various complications in a patient.
Complications like CAV, hypertension, and diabetes. In this
particular case, The cholesterol level could indicate the
possibility of the left ventricular thickening.
· Kidney Profile- of the patient which includes blood uric acid,
the blood urea nitrogen, and serum creatinine) – This testing
allows me to see if the patient's complication is affecting his
organs like the kidney.
· Eye examination - to assess the patient for hypertensive
retinopathy complications.
Question 8 – Top Two Diagnoses
My first main diagnoses for the patient would be type 2 level
Hypertension based on his two testings (his highest readings
was 176/92 mm Hg; the second reading was 174/94. The second
diagnosis would be pre- Diabetes based on the patient fasting
blood glucose level of 154 mg/dl. Normal blood glucose should
be under 125 mg/dl. On the other hand, his HbA1c is also higher
at a range of 7.8%, which indicates abnormal blood glucose, and
his blood sugar level is not controlled. A normal HbA1c should
be lower than 6%
Question 9 -Pharmacologic Plan for this condition
The pharmacologic plan will focus on the first and second
medication therapy to implement for the patients based on the
two diagnoses. The plan will start with the assessment question
specifically to see if the patient is on any maintenance
medication treatment and if the answer is yes. Therefore, I will

8. adjust either the current dosage, increased it, or change the
medication to another drug.
If the answer is no, then I will start the patient on a low dose of
blood pressure medication treatment as soon as possible. Based
on his assessment, the patient is at a higher risk of
cardiovascular complications. Lifestyle adjustments alone will
not be sufficient enough to control his pathology. There are
multiple medications to start the patient on based on research
evidence. Based on the information given and diagnoses, the
patient’s hypertension is categorized as level 2 grade
hypertension (systolic value between 160-179 mmHg or the
diastolic values between 100-109 mm HG). I will prescribe
angiotensin-converting enzyme (ACE) inhibitors or angiotensin
II receptor blockers (ARBs). These medications are the first line
of drug for patients with diabetes diagnoses who have elevated
blood pressures above 140/90 mm Hg (Hu, Han, Ge, Wu,2015).
I will look at metformin as the initial pharmacologic agent for
the treatment of his diabetes diagnosis.
Question 10- Lifestyle Modification
Patient education is important. Based on the patient's current
status and conditions, lifestyle modifications, in addition to the
appropriate medication, is important in reducing his risk for
cardiovascular complications. These are the lifestyle
modification given to the patient:
· The patient needs to exercise 2 to 3 times a week as tolerated
(30 minutes per day) and to maintain a healthy and sustainable
weight.
· The Patients need to reduce any saturated intake and eat
healthy foods.
· The patient needs to monitor his blood sugar daily. Supply,
teaching, and resources will be provided (Challa, Upaluri,2020)
· The patient needs to meal prep, especially because of his job
to be able to maintain a proper eating diet and habits.
· Patients need to limit the intake of sodium to a maximum 100
mmol/ day.
· Ensure that the patient is having an adequate intake of both

9. Mg and Ca. and potassium.
· Place the patient on a smoking patch and encourage him to
stop smoking.
· The patient needs to limit alcohol intake and also coffee
drinks.
· The Patient needs to drink a lot of fluids throughout the day to
prevent dehydration.
References
Gabb, G. M., Mangoni, A. A., Anderson, C. S., Cowley, D.,
Dowden, J. S., Golledge, J., & Schlaich, M. (2016). Guideline
for the diagnosis and management of hypertension in adults—
2016. Medical Journal of Australia, 205(2), 85-89.
Poulter, N. R., Dolan, E., Gupta, A. K., O’Brien, E.,
Whitehouse, A., & Sever, P. S. (2019). Efficacy and Safety of
Incremental Dosing of a New Single-Pill Formulation of
Perindopril and Amlodipine in the Management of
Hypertension. American Journal of Cardiovascular
Drugs, 19(3), 313-323.
Volpe, M., Gallo, G., Battistoni, A., & Tocci, G. (2019).
Highlights of ESC/ESH 2018 Guidelines on the management of
hypertension: What every doctor should know.
Dornbush S, Turnquest AE. (2019) Physiology, Heart Sounds.
In: StatPearls [Internet]. Treasure Island (FL):
StatPearls Publishing; Retrieved on October 17 from
https://www.ncbi.nlm.nih.gov/books/NBK541010/
Amin H, Siddiqui WJ. (2019) Cardiomegaly. ,In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing;
Retrieved on October 17 from:

10. https://www.ncbi.nlm.nih.gov/books/NBK542296/
Liu, Q., Wu, X., & Ma, X. (2018). An automatic segmentation
method for heart sounds—biomedical engineering online, 17(1),
106.
Aronow W. S. (2017). Hypertension and left ventricular
hypertrophy. Annals of translational medicine, 5(15), 310.
Hu, C. S., Han, Y. L., Ge, J. B., Wu, Q. H., Liu, Y. N., Ma, C.
S., Tkebuchava, T., & Hu, D. Y. (2015). A novel management
program for hypertension. Cardiovascular diagnosis and
therapy, 5(4), 316–322.
Challa HJ, Tadi P, Uppaluri KR. (2020) ,DASH Diet (Dietary
Approaches to Stop Hypertension) In: StatPearls [Internet].
Treasure Island (FL): StatPearls Publishing; 2020 Jan-.
Available from:
https://www.ncbi.nlm.nih.gov/books/NBK482514/
Unit IV (A)
QUESTION 1
A recent new hire has joined Fig Technologies. The individual
is of a cultural background that is perceived as very different
from the mainstream workplace environment. As a manager,
how would you integrate this individual into the organizational
culture and address any existing perceptions?
Your response must be at least 500 words in length.

11. QUESTION 2
Fig Technologies has acquired a network services firm that has
several Native American workers. The events team in the local
office is putting together the calendar of events for the next
year. How do you educate, inform, and assimilate Native
American culture and traditions into a self-described White
Anglo-Saxon Protestant workplace environment?
Your response must be at least 500 words in length.