Psychiatric: Non-contributory Paper.

Physical examination:

Vital Signs: Height: 5 feet 1 inches Weight: 175 pounds BMI: 32, Obese, BP 160/92, T 98.0, P 111, R 22 and non-labored

ORDER CUSTOM, PLAGIARISM-FREE PAPER

HEENT: Normocephalic/Atraumatic, Bilateral cataracts; PERRLA, EOMI; Teeth intact. Negative for gum disease. NECK: Neck supple, no palpable masses, no lymphadenopathy, no thyroid enlargement. LUNGS: + Mild Crackles on inspiratory phase not clearing with cough. Equal breath sounds. Symmetrical respiration. No respiratory distress. HEART: Normal S1 with S2 during expiration. An S4 is noted at the apex; + systolic murmur noted at the right upper sternal border without radiation to the carotids. Pulses are 2+ in upper extremities and 2+ in pedal pulses bilaterally. 2+ pitting edema to her knees noted bilaterally. ABDOMEN: No abdominal distention. Nontender. Bowel sounds + x 4 quadrants. No organomegaly. Normal contour; No palpable masses. GENITOURINARY: No CVA tenderness bilaterally. GU exam deferred. MUSCULOSKELETAL: + Heberden’s nodes at the DIP joints, hands. + Crepitus, bilateral knees. Slow gait but steady. No Kyphosis. PSYCH: Normal affect. Cooperative. SKIN: No rashes. Positive for dry skin.

Labs: Hgb 13.2, Hct 38%, K+ 4.0, Na+137, Cholesterol 228, Triglycerides 187, HDL 37, LDL 190, TSH 3.7, glucose 98.

Primary Diagnosis: Congestive Heart Failure (CHF)

Secondary Diagnoses: Primary Hypertension, Obesity, Osteoarthritis (OA)

Differential Diagnosis: Peripheral Vascular Disease (PVD)

Plan:

Medications: Tylenol 650 mg PO Q4 hours as needed for arthritis pain

Labs: UA; Brain natriuretic peptide (BNP); LFTs and TSH; 12-lead EKG, Chest X-ray; Initial 2D echo with Doppler; Ankle-brachial index.

Additional lab results:Echo results 1 week ago: Left ventricular EJ Fraction decreased to 35 %

BNP – not available.

As a future FNP, you need to determine the medications for CHF/ASCVD. (Arteriosclerotic Cardiovascular Disease).

Questions:

1. According to the ACC/AHA guidelines, what medications should this patient be prescribed?

2. Does he need medication(s) given his history of MI?