Lorene is a 60-year-old African American female who presented with shoulder discomfort and shortness of breath during exercise. She has a history of hypertension, metabolic syndrome, and dyslipidemia. On examination, her blood pressure was 146/90 and a random glucose was 130 mg/dL. She has multiple risk factors for cardiovascular disease.

1. Cardiovascular Case Study Discussion
Question DescriptionRequirements:Setting: large rural clinic; family practice clinic that
employs physicians, physician assistants and nurse practitioners. You open the chart to
review for your next patient, and you see it is Lorene M. Lorene is a 60 year-old African
American female with a history of hypertension and known documented metabolic
syndrome following lifestyle changes per her request. You note she is not due for a follow
up at this time, so you look at the chief complaint.CC: Shoulder discomfort and SOB with
exercise 3 days ago.You enter the room and introduce yourself to Lorene who is sitting in
the chair. You ask what brings her in today. She smiles, shaking her head and says “My
daughter made me come, I feel fine. I am way too busy to be here today. Since my last visit,
three months ago, I joined a gym and with the support of my daughter, we are going two
days a week.” However, three days ago Lorene felt short of breath while in dance class. She
developed what she calls as “a discomfort” that radiated back and up between her shoulder
blades while at the peak of her exercise routine. She also felt a little nauseous and sweaty.
Once she stopped dancing, all symptoms resolved in about 3 minutes and they have not re-
occurred.PMHx: Reports general health as good. She has been trying to lose weight through
exercise and avoiding processed foods. She admits that food is a large part of her
background and heritage in social activities and so it is difficult to make healthy choices. She
had been feeling great since starting to work out and has lost 2 inches around the abdomen.
She describes having lots of energy until this episode three days ago. Now she is a little
concerned because she feels a little more tired than usual. She has not participated in
anything strenuous and has not worked out sinceChildhood/previous illnesses: chicken
pox.Chronic illnesses: Hypertension, Metabolic Syndrome, and Dyslipidemia.(Lifestyle
management was initiated per patient preference) Gestational Diabetes with 3 pregnancies
managed with InsulinSurgeries: T and A, cholecystectomyHospitalizations: None aside from
surgeries listed aboveImmunizations: Does not receive the flu shot.Allergies: Reports
remote Hx allergy to metformin. Describes a GI disturbance.Blood transfusions:
NoneCurrent medications: None. Stopped Lisinopril one month ago as she read that it can
cause a cough as one if its side effects. Prefers to get the BP under control with diet and
exercise.Social History: Married for 20 years. Children are grown and have moved out of the
house but all live locally and are close to their parents. Lorene works full time as a CEO of a
successful marketing company and travels often for work. She eats out a lot while
entertaining business clients. She enjoys beer and wine and the occasional “social” cigarette
when she gets together once weekly with her girlfriends.Family History: Parents are

2. deceased. Father had lung cancer and mother died from complications of a stroke due to
complications of diabetes type 2. Brother died at 44 from malignant melanoma. Other sister
and brother are healthy but they also have diagnoses of metabolic syndrome.PE: Height:
5’8″ weight: 220 pounds; BMI 33.5 vital signs: BP 146/90 P 70 Sao2 97% Random glucose
finger stick in office: 130mgs/dl General: African American female in NAD. Alert, oriented,
and cooperative. Pain: 0/10 at present Skin: Skin warm, dry, and intact. Skin color is light
skinned brown, no cyanosis or pallor. HEENT: Head normo-cephalic. Hair thick and
distribution even throughout scalp. Eyes: Sclera clear. Conjunctiva: white, PERRLA, EOMs
intact. No AV nicking noted. Ears: Tympanic membranes gray and intact with light reflex
noted. Pinna and tragus non-tender Nose: Nares patent without exudate. Sinuses non-
tender to palpation, Right-sided Deviation Throat: Oropharynx moist, no lesions or exudate.
Teeth in poor repair, gums reddened and receding, filled cavities noted. Tongue smooth,
pink, no lesions, protrudes in midline. Neck supple. No cervical lymphadenopathy or
tenderness noted. Thyroid midline, small and firm without palpable masses. Mild JVD in
recumbent position Lungs: Lungs clear to auscultation bilaterally. Respirations unlabored.
No rashes or vesicles noted on chest. CV: Heart S1 and S2 noted, RRR, no murmurs, noted.
No parasternal lifts, heaves, and thrills. Peripheral pulses equally bilaterally. PMI 5th ICS
displaced 4cm laterally. Trace edema in lower extremities. Abdomen: Abdomen round, soft,
with bowel sounds noted in all four quadrants. No organomegaly noted.Labs from 3 months
ago:AIC 6.4% Fasting glucose 135mgs/dl Total Cholesterol: 230 Triglycerides 180mgs/dl
Ldl 180 Hdl 38EKG today in officeWeek 3 Discussion Questions:What Leads Demonstrate
the ST Depression?Is Lorene Hypertensive per ACA 2017 Guidelines? Compare the ACA
guidelines to JNC 8 guidelines and discuss what treatment you recommend for her BP and
why.What is the Primary diagnosis causing Lorene’s chest pain? Include ICD 10 codes (no
differentials)What other secondary diagnoses does Lorene have that should be addressed?
(Include the rationale and a reference for your diagnoses)Design a treatment plan and
discuss how each intervention is applicable to Lorene’s case. Consider the following
interventions:LabsDurable Medical Equipment Diagnostic tests- discuss the
goal/purposeAny consultation with outside providers/servicesMedications- discuss why
you chose each specific medicationReferrals- who and whyFollow up- why and
whenEducation- specific and measureableLifestyle Changes- specific to her cultural
preferences, values and beliefs