What is the best drug(s) of choice for this patient?

/in /by

Jose is a 47 year old morbidly obese Latino male who presents to the clinic for follow up evaluation of headaches, dizziness, ringing in his ears and
frequent urination- He reports having a headache that “comes and goes” with ringing in his ears and sometimes he sees spots- Jose has taken
acetaminophen and states that seems to help- Due to his work schedule of six 12 hour days, Jose has not had preventive care- He reports fatigue
and is depressed regarding his current income situation- Jose has just been laid off for the season and will lose his insurance in 30 days until the
restart of the harvesting season in March- He is concerned about paying for any health care that may go beyond his benefit period- Jose lives with
his pregnant wife, who does not work, and their seven children in a three bedroom one bath house that they share with his parents and his brother’s
family of three-

Review of Systems Subjective Data

General: occasional fatigue, gradual weight gain over the past ten years

HEENT: (+) visual and hearing changes with HA; (-) cold or recent upper respiratory

changes, (-) rhinorrhea or nose bleeds,

Cardiac: (-) chest pain or tightness, no palpitations

Respiratory: no asthma, (+) snores at night

GI: (-) pain, nausea, vomiting, constipation, visible fecal blood, (+) GERD, reports occasional indigestion after meals,

GU: (+) frequent urinary for 1 month with increased thirst

MS: (+) chronic bilateral shoulder and low back pain for 7+/- years, takes ibuprofen prn-

Neuro: (+) headaches 2- 3 times a week relieved with acetaminophen, (+) dizziness, sees spots with HA which are not related to activity,
weakness, (+) numbness and tingling in both feet,

changes in speech or memory

Skin: (-) rashes or lesions

Allergies

Psych: (+) Depressed about income, wife is unable to work and is pregnant

7 children ages 2 years-13 years-

Past Medical History: Denies problems No preventative care- Only acute care for cold or flu-

Past Surgical History: None

Medications: None

Social History: (-) substance abuse, (+) ETOH, drinks 1-2 beers a day and 5-6 beers on the weekend with family on Saturday and Sunday. Drinks 2
cups of coffee with cream and sugar in the AM, does not exercise except working in the fields picking broccoli, likes to watch TV at night, eats a high
carbohydrate diet of rice, beans, potatoes, corn and tortillas (8-10 a day) eats at home, does not eat out often- Drinks water, no sodas orjunk food-
Reports drinking freshly made jimaca (hibiscus) tea with sugar and fresh cucumber lime drink with sugar three times a week- Rarely eats deserts-
Family History: Parents and siblings all living- 2 brothers and 3 sisters- (+) hypertension – father and mother, 2 brothers and 2 sisters (+) diabetes-
father, mother, 1 brother and 1sister, (+) coronary heart disease- father, mother, 1 brother, (+) hypercholesterolemia- father, mother, 1 brother, 2
sisters

Physical Examination – Objective Findings

Ht- 64 inches Wt- 294 lbs. BP 176/104 mmHg HR: 92 RR: 24 TI 98.8 F

General: Well appearing, well groomed, NAD, looks stated age, morbidly obese

Eyes: PERRLA, Fundoscopy with no AV nicking or copper or silver appearance, no

papilledema, EOMI

Neck: supple, (-) lymphadenopathy, (-) thyromegaly,

CV/Heart: RRR, (-) murmur, rubs or gallops, lifts or heaves, tenderness to palpate, (-) carotid bruits, (-) pedal edema

Lungs: CTA bilaterally, respirations equal and unlabored

Abdomen: (+) BS x 4, soft, round, non-tender, (-) masses, organomegaly, bruits

MS: (+) steady gait, FROM all EXT, no cyanosis, clubbing, pedal pulses present, feet warm, monofilament test abnormal at R great toe, 2+ patellar
DTR,

Neuro: CN 2-12 grossly intact, (-) Rhomberg, (-) Pronator drift, (-) Dix Hallpike

Skin: (-) rashes or lesions, color even WNL, hair normal distribution

Psych: appears anxious

Previous Lab and Diagnostic Testing: None available- Reports labs done in Mexico 10 years ago, does not remember results-

Current Lab Test Results – Fasted 12 hours – completed 1 week prior to clinic

appointment

Complete Blood Count/ Basic Metabolic Panel

WBC 5-0

RBC 4-8

Hgb14

HCT 45-2

MCV 78

MCH 27

mum…“ flan i

Glucose 238
Creatinine 0-6 mg/dl
Carbon dioxide 25 mEq/L
Chloride 100 mquL
Potassium 4-0 ITIEQ/L
Sodium 142 mg/dl
Calcium 9 mg/dl

BUN 16 mg/dl

AST 68

ALT 82

Triglycerides 457
Cholesterol 368

LDL 325

HDL38

vnD16

A1c 10-9

TSH 4-95

CRPG

UA

Clear, pale yellow

pH 5-4

Specific gravity 1-021
Protein negative
G’UCOSG 500++
Ketones Neg

Blood Neg

1- Based on the patient’s labs and the Subjective and Objective data, what are the patient’s diagnoses? (Hint: There are at least

2- Briefly discuss the pathophysiology of the top three diagnoses-

3- Discuss the guidelines for diabetes management- What is the best drug(s) of choice for this patient? What are the benefits of the drug(s) for this
patient? Explain the pharmacological action of the drug(s)- Explain the importance of aspirin in diabetes- Describe how these medications work to
stabilize and provide optimum health-

4- Discuss the JNC 8 guidelines for hypertension management- What is the best drug(s) of choice for this patient? What are the benefits of the
drug(s) for this patient? Explain the pharmacological action of the drug(s)- Describe how these medications work to stabilize and provide optimum
health-

5- Discuss the AACE 2017 guidelines for dyslipidemia management- What is the best drug(s) of choice for this patient? What are the benefits of the
drug(s) for this patient? Explain the pharmacological action of the drug(s)- Describe how these medications work to stabilize and provide optimum
health-

6- Discuss non-pharmacological interventions to assist Jose in reaching his optimal health- This includes supplements/alternative/integrative
medicine…-

7- List factors that increase the patient’s risk for cardiovascular disease (including labs)-