Select the Week 2 Assignment help – Discussion link above and create thread to post the initial substantive response to the Assignment help – Discussion Question. The initial response must address all aspects of the Assignment help – Discussion Question and contain at least two citations with corresponding references. You must post one response each, to at least three classmates, in a topic-focused discussion, following the instructions in the Assignment help – Discussion Questions. Respond to any direct comments or questions initiated by the instructor or a classmate. Please follow the grading rubric for Assignment help – Discussions
For week 2 discussion, select ONE of the two cases below. After you have read it thoroughly, respond to the questions. Responses should be substantive and meet the requirements of the weekly discussion board.
Case 1
A 47-year-old female patient is in for a follow-up visit to monitor her treatment for type 2 diabetes. You added regular insulin to her treatment regimen last month. She tells you that she has not had any symptoms of hypoglycemia with the new plan and her glucose levels have been between 60 and 80. She tells you that her visit to her cardiologist went well and she was prescribed a new medication, atenolol.
Assignment help – Discuss the problems and/or complications that might result when a patient with diabetes is treated with a beta blocker.
Would there be a difference if the beta blocker was not atenolol?
Is there something about the rest of her treatment plan that needs to be addressed?
Case 2
Jack is a 54-year-old patient who has difficulty coming in for primary care visits. He sees cardiology, pulmonary clinic, and endocrine clinic for his comorbid conditions of diabetes mellitus, postcoronary artery bypass grafting (CABG) 2 years ago, and mild chronic obstructive pulmonary disease issues from a 30 pack year history of smoking. His last visit with you was over a year ago. Today, your registered nurse brings you a telephone triage call requesting a refill of his Crestor prescription, which was ordered by cardiology soon after his CABG. Per the electronic links to the cardiology service within your facility, the medication was due to be renewed about 2 months ago. His last lipid labs were a year ago and his last complete metabolic panel (CMP) was done at the same time. He was recently at the pulmonary clinic and his last recorded HgA1C was 9.0 from a visit to endocrine 4 months ago. Review of records include a prescription for his hypertension (Lisinopril 20 mg daily), metformin 1,000 mg twice a day for his diabetes, and no known medications for his pulmonary issues. The Crestor prescription appears to have multiple dosing levels over the past few refills. His last vital signs were blood pressure (BP) 170/110 mm Hg, pulse 88, and respirations 22. His body mass index is 30 and he indicates a pain level of four out of five. His pulse oximetry was 92% on room air.
How do you respond to this telephonic request?
What steps are required to get Jack’s therapeutic plan under control?
What is the role of the primary care provider (PCP) in this scenario?
Week 2 case 1 kl
In this talk, there is a 47-year-old woman with type 2 diabetes who is the patient. Type 2 diabetes is also called “adult-onset diabetes” because it usually starts in adults. Most people with type 2 diabetes still make insulin, but they have problems with their insulin receptors, are resistant to insulin, don’t make enough insulin to meet the body’s needs, or have a different way of using glucose. Type 2 diabetics are usually treated first with oral medications. However, insulin or medication resistance can happen, making type 2 diabetics need insulin. “BG (blood glucose) levels closer to the target range can significantly reduce the risk of complications associated with DM (diabetes mellitus),” which is also important for the patient’s health (Woo & Robinson, 2020). This is true for both type 1 and type 2 diabetes. Some of the problems that can happen are neuropathy, high blood pressure, and heart problems. “There is a strong link between type 2 diabetes mellitus and heart failure. People with type 2 diabetes mellitus are more likely to get heart failure” (Masarone et al., 2021).
In addition to managing her diabetes, the woman has another problem. She needs to see a cardiologist for an unnamed problem. The doctor told her to take the beta-blocker atenolol to treat her problem. “Atenolol is a beta-1 selective adrenergic antagonist from the second generation that is used to treat high blood pressure, angina pectoris, and acute myocardial infarction” (Rehman et al., 2021). Atenolol is given to people with high blood pressure, angina, or an acute myocardial infarction. It is not known why the patient is taking it. Acting on the heart it lowers the heart rate, reduces blood pressure, and decreases cardiac contractility. As a group, beta-blockers affect how blood sugar is managed by making insulin work better at lowering blood sugar. Levobunolol and metipranolol are two beta blockers that are listed as exceptions.
“A blood sugar level of less than 70 mg/dL is said to be hypoglycemia” (Woo & Robinson, 2020). Even though it may say less than 60 mg/dL in some books. The patient’s blood sugar has been in the 60s and 70s since she started taking insulin. This means that the person has low blood sugar. Hypoglycemia symptoms may not show up until the blood sugar is even lower. This varies from patient to patient, and if the patient has no symptoms, they are said to be asymptomatic. That doesn’t mean beta-blockers shouldn’t be given, but more research is needed to figure out if the insulin dose, the atenolol dose, or both need to be lowered. As was said, there are two beta blockers that don’t have the same effects on blood sugar and could be a better choice. Before we can make that choice, we need to know what the cardiologist thinks is wrong and how we should treat it. As doctors, we need to know if she has been taking the atenolol and for how long. This will help figure out if there are few problems or a chance of problems if she hasn’t taken the atenolol yet. If she is already taking atenolol, cutting back on the insulin would help keep her in a better therapeutic range. “The goal for the therapeutic range is BG levels between 80 and 130 mg/dL before a meal” (Woo & Robinson, 2020). At the time of the patient’s appointment, she is below the therapeutic range.
References
Masarone, D., Pacileo, R., & Pacileo, G. (2021). Use of disease-modifying drugs in diabetic patients with heart failure with reduced ejection fraction. Heart Failure Reviews. https://doi.org/10.1007/s10741-021-10189-4
Rehman, B., Sanchez, D., & Shah, S. (2021). Atenolol – StatPearls – NCBI Bookshelf. NCBI. Retrieved September 5, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK539844/
Woo, T. M., Wynne, A. L., & Robinson, M. V. (2020). Pharmacotherapeutics for Advanced Practice Nurse Prescribers(Fifth). F.A. Davis Company.
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Assignment help – Discussion #2
Case #1
A 47-year-old female patient is in for a follow-up visit to monitor her treatment for type 2 diabetes. You added regular insulin to her treatment regimen last month. She tells you that she has not had any symptoms of hypoglycemia with the new plan and her glucose levels have been between 60 and 80. She tells you that her visit to her cardiologist went well and she was prescribed a new medication, atenolol.
Assignment help – Discuss the problems and/or complications that might result when a patient with diabetes is treated with a beta blocker.
According to Tsujimoto, et al (2017) The use of beta blockers in diabetes mellitus patients is associated with an increased risk for cardiovascular events. In addition, the incidence of severe hypoglycemia, which required assistance from medical personnel and was confirmed by blood glucose levels <50 mg/dL, was significantly higher in diabetes mellitus patients on beta blockers than in those not on beta blockers.
Would there be a difference if the beta blocker was not atenolol?
Anti-hypertensive therapies such as diuretics, ACE inhibitors and calcium antagonists have been effective in reducing cardiovascular events in type 2 diabetes. Beta-blockers have a poor image as a potential therapy due to adverse effects and insulin-resistance.
Is there something about the rest of her treatment plan that needs to be addressed?
The patient needs to change treatment with her cardiologist. Search according to her condition and what the cardiologist wants to manage, a class of medication that does not affect the diabetes treatment.
Reference
Tsujimoto, T., Sugiyama, T., Shapiro, M. F., Noda, M., & Kajio, H. (2017). Risk of Cardiovascular Events in Patients With Diabetes Mellitus on β-Blockers. Hypertension (Dallas, Tex. : 1979), 70(1), 103–110. https://doi.org/10.1161/HYPERTENSIONAHA.117.09259
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Week 2 Case 2
Jack is a 54-year-old patient who has trouble getting to his primary care appointments. He goes to the cardiology, pulmonary, and endocrine clinics for his diabetes mellitus, post coronary artery bypass grafting (CABG) from two years ago, and mild chronic obstructive pulmonary disease problems from a 30-pack a year history of smoking. The last time he came to see me was more than a year ago. Today, my registered nurse brings me a phone triage call from him asking for a refill of his rosuvastatin (Crestor) prescription. This was ordered by cardiology soon after his CABG. Based on my facility\’s electronic links to the cardiology service, the medicine should have been renewed about two months ago. His last lipid labs were done a year ago, at the same time as his last complete metabolic panel (CMP). He just went to the pulmonary clinic, and the last time his HgA1C was checked, 4 months ago, it was 9.0. Reviewing his records shows that he takes Lisinopril 20 mg every day for his high blood pressure, metformin 1,000 mg twice a day for his diabetes, and nothing for his lung problems. Over the last few refills, the rosuvastatin (Crestor) prescription seems to have had different doses. His last vital signs were 170/110 mm Hg for blood pressure (BP), 88 for pulse, and 22 for breathing. He has a body mass index (BMI) of 30, and he says his pain is a 4 out of 5. On room air, his pulse oximetry was 92%.
How do you respond to this telephonic request? First, I need to know where the pain is, and what type of pain he is having. Then I can advise whether he needs to go to the emergency room right away or come to the clinic for his follow-up. He will need to come to the clinic since his last metabolic panel and lipid panel were drawn a year ago.
What steps are required to get Jack’s therapeutic plan under control? The first thing I need to do is a complete assessment of Jack. I need to find out what’s stopping Jack from keeping his appointments. He might not understand his treatment plan, he might need a telehealth provider if his insurance will cover a telehealth visit, or he might need a case manager to help with his situation at home or get him to his appointments. I’ll check with Jack’s cardiologist about his care plan, since the cardiologist might need to keep an eye on his rosuvastatin (Crestor). When I’m done evaluating this patient, I’ll call the pulmonary clinic to find out what’s going on. I will encourage Jack to follow up with a dietitian for his BMI of 30. He will need a complete blood count (CBC), a complete metabolic panel (CMP), and a thyroid stimulating hormone (TSH) test because hyperthyroidism or hypothyroidism can affect blood pressure and heart rate. I will call his cardiologist and ask for his records, call his endocrinologist for his records, and call the pulmonology clinic for his records. I will try to find out why Jack isn’t taking any medicine for his mild chronic obstructive pulmonary disease. After the patient’s blood work and vital signs are done, Jack’s current treatment, which includes Lisinopril, may need to be changed. Before I change the amount of rosuvastatin (Crestor), I will talk to the cardiologist about his care.
Understanding the effects of inflammatory markers, especially C-reactive protein (CRP), has made it less important to only treat low-density lipoprotein (LDL) (LDL). There is a chance that the antioxidant effects of statins are at least as helpful as their effects on lipids. This finding led the FDA to approve statin therapy (especially Crestor) for people without cardiovascular disease (CVD) whose CRP levels were above 2 mg/L and who had at least one other risk factor, like high blood pressure, a strong family history, or smoking. Non-high-density lipoprotein (HDL)-C levels are more closely linked to cardiac events than LDL and apolipoprotein B levels, especially in diabetics. Individual risk recommendations now take into account this newer focus on predicting non-LDL risk (Woo & Robinson, 2019).
Statins are now the standard treatment for Acute Coronary Syndrome, no matter what your cholesterol level is. Statin, which is an HMG-COA (hydroxymethylglutaryl-coenzyme A) reductase inhibitor, is one of the antihyperlipidemic drugs used to lower the amount of fat in the body. These medicines seem to either stop the body from making cholesterol or make it break down faster. They are used to prevent and treat heart disease and hyperlipidemia when non-drug treatments haven’t been able to bring down cholesterol levels. But they have been linked to a number of bad effects, such as myalgia, myopathy, rhabdomyolysis, and type 2 diabetes. Because of this, many people stop taking statins without talking to their doctors about it because they have side effects. As a result, their risk of cardiovascular events goes up. Increases in creatine kinase (CK) that are normal or not very big could cause myopathic muscle weakness. Some people who take statins show plasma activity, which is usually accompanied by a lot of physical activity. A patient may sometimes have a big rise in CK activity, which is often accompanied by widespread pain or muscle weakness. If the medicine isn’t stopped, myoglobinuria could cause a lot of damage. Muscle soreness is more likely to happen if you are older than 75, a man, if you drink too much alcohol, if you have kidney or liver disease, or if you take statin-metabolism-inhibiting drugs like erythromycin. Statins can also cause severe myopathy and rhabdomyolysis, which are linked to a genetic variation in a protein called anion-transporting polypeptides 1B1 (Ihab et al., 2022).
Rosuvastatin (Crestor) works by stopping 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase from doing its job. This enzyme slows down the production of mevalonic acid from HMG-CoA, which is the rate-limiting step in making cholesterol. This also leads to more low-density lipoprotein (LDL) receptors on the membranes of hepatocytes and more LDL being broken down. High-sensitivity C-reactive protein levels are also lowered by drugs that block HMG-CoA reductase (CRP). Also, they have many different effects, such as stopping platelets from sticking together, stopping blood from clotting, reducing inflammation at the site of a coronary plaque, and making endothelial function better (Bajaj & Giwa, 2022).
About 10% of a radiolabeled dose of rosuvastatin (Crestor) could be found in the body as metabolites. Statin medications have different pharmacokinetic properties, but rosuvastatin (Crestor) is unique in that it has a half-life of 19 hours, a bioavailability of 20%, a protein binding of 88%, a hydrophilic solubility, is metabolized by CYP2C9, and is mostly eliminated in the feces (90%), with only 10% leaving the body through the urine (Bajaj & Giwa, 2022).
Ischemic heart disease can only be treated and stopped by taking statins. With a frequency of 73.5%, the use of statins is strongly linked to muscle soreness. Because of this, patients tend to stop taking their prescribed medicines. So, people at high risk can keep taking the medication if they change the right dose or switch to a different type of statin to avoid side effects. Also, it’s important to rule out other causes of myopathy, like physical activity, a broken bone, thyroid problems, or an infection (Ihab et al., 2022)
What is the role of the primary care provider (PCP) in this scenario? The primary care provider needs to work in collaboration with other health care providers and coordinate care, and follow certain national guidelines before changing, increasing, or prescribing any medications. Guidelines that at the present moment I am not fully familiar with, but in the near future those guidelines from the American Heart Association and the Joint National Committee (JNC8) will be the ones to follow.
References
Bajaj, T., & Giwa, A. O. (2022). Rosuvastatin. StatPearls Publishing, 1-6. https://www.ncbi.nlm.nih.gov/books/NBK539883/
Ihab, S., Abdulaziz, B., Hassan, A., Hisham, A., Hassan, A., & Alghamdi, A. (2022). Prevalence of self-reported muscle pain among statin users from National Guard Hospital, Riyadh. Cureus, 14(3). https://0624q2l5d-mp01-y-https-doi-org.prx-keiser.lirn.net/10.7759/cureus.23463
Woo, T. M., & Robinson, M. V. (2019). Pharmacotherapeutics for Advanced Practice Nurse Prescribers (5th ed.). F. A. Davis Company. https://bookshelf.vitalsource.com/books/9781719642149
week 2
Response to C
The high level of HgA1C indicates that Jack has uncontrollable diabetes and COPD. The patient further has high defects, as shown by the bypass process the patient underwent two years ago. Additionally, the patient had an unfilled prescription of Crestor that was due two months ago, indicating that Jack might not have taken the medication for sixty days, which might have led to an increased cholesterol level. The current prescription might not have been influential in the treatment. Jack does not have any recent CMP and lipid test reports. There is a need for a current assessment of the body condition, and there is a need for the assessment of his body condition and blood cholesterol level is also; any drug can be administered. The telephonic requests should not be accepted, and Jack should be asked for an in-patient visit to assess the lipid levels and the Comprehensive Metabolic Panel before any medication is administered to facilitate the treatment of the condition.
Steps required to get Jack’s Therapeutic Plan under Control
Performance of a lipids test and CMP panel to determine the present level of lipids and other metabolic. The test is critical as it would give information on the metabolic products that accumulate in the body and evaluate liver and kidney functions (Sollnica et al., 2020).
Determination of the dosage of Crestor or other relevant medication for controlling cholesterol is applicable per the lipid test and CMP panel.
Assessment of the blood glucose and HgA1C level since Jack\’s last check-up was performed four months ago. This would be significant in assessing whether or not the medication regime is working.
Based on the current blood glucose level, it would be important that the medication dosage is modulated, and insulin should be included, if need be, to help manage the blood sugar.
Assessment of the sources of the pain of the patient and the determination of the underlying condition causing the pain.
It is important to informs Jack about the need for weight reduction through physical activities into their daily regimen. This would help reduce pressure on the cardiovascular system and further aid in providing a better response to diabetic medication (Surabhi et al., 2020).
Role of Primary Care Provider
The primary care provider performs various roles, which include the assessment of Jack\’s pain and the prescription of medication. The primary care provider further informs the patient about the lifestyle changes required for effective treatment. The other role is educating patients about the test to be performed on the patient and the outcome. The primary care provider also advises patients regarding the side effects of the medication and the treatment plan (Giannitrapan et al., 2018).
References
Giannitrapan, K. F., Glassman, P. A., Vang, D., McKelvey, J. C., Day, T., & Dobscha, S. K. (2018). Expanding the role of clinical pharmacists on interdisciplinary primary care teams for chronic pain and opioid management. BMC series, 19(107). https://bmcprimcare.biomedcentral.com/articles/10.1186/s12875-018-0783-9
Solnica, B., Sygitowicz, G., Sitkiewicz, D., & Cybulska, B. (2020). 2020 Guidelines of the Polish Society of Laboratory Diagnostics (PSLD) and the Polish Lipid Association (PoLA) on laboratory diagnostics of lipid metabolism disorders. Polish Society of Laboratory Diagnostics, 252. https://onlinelibrary.wiley.com/doi/abs/10.1002/ptr.6328
Surabhi, B., & Jamie, C. (2020). COVID-19–Related Home Confinement in Adults: Weight Gain Risks and Opportunities. Perspective COVID-19 and Obesity, 28(9). DOI:10.1002/oby.22904
