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Mrs. Jones calls your office stating that she is tired and has swollen feet. You work her into your schedule immediately. She is a 72-year-old woman with a history of hypertension. She does not take daily diuretics but has Lasix at home “just in case”. She took one this morning. It is not on your medication list, and you don’t know the strength. Her blood pressure in the office is 160/82 mmHg and her weight is up 12 pounds since you saw her a month ago. Her last echocardiogram was 3 months ago and demonstrated an ejection fraction of 55%. Her primary complaints are tiredness and a cough for the past week. On exam you note jugular venous distention of about 6 cm, and she has pulsatile hepato-jugular reflux, clear lung sounds in all fields, and an irregular heart rate at 100. No S4 or S3. Abdomen is soft, but a little distended you think. She has 2(+) dependent edema to almost her knees, bilaterally. Based on the assessment and findings noted above, which of the following diagnostic tests will help you decide how to treat Mrs. Jones? Select all correct answers. 

Which anti-depressant is the preferred option for depression post-MI?

Susan Bridge is a 58-year-old Caucasian female who just recently moved into town and is seeing the NP today to establish care and go over her medication and treatment plan.   Susan checks her BP at home 3x a week and average home BP readings are 144/86 mmHg.   PMH: HTN dx. 5 years ago, Hyperlipidemia dx. 5 years ago. OB hx:  G:3, P: 3.  Gestational DM, preeclampsia, menopausal 1 year Family Hx:  Dad alive 88 y – DM type II, HTN, Hyperlipidemia, CVD with an MI at age 67.  Mom alive 85 y – DM type II, Hyperlipidemia, depression Medications: Lisinopril 10 mg/day, Atorvastatin 40 mg/day, multi-vitamin Social Hx:  non-smoker, ETOH wine 3 glasses/week, full-time work as an accountant, exercise – short walks 2-3 x a month.  Doesn’t have time to cook – eats fast-food 2-3x a week, eats soup from a can 3-4x a week.  Likes to reward herself on the end of the day with a couple of pieces of pie.   Lipid panel – 1 week ago while on statin therapy:   Total cholesterol 142 LDL 135 HDL 35 Non-HDL: 107 VS: BP: 158/84 mmHg.   RR: 16 HR:  88 Pulse-ox: 95% RA BMI:  29 Address each question separately:   1.  Identify risk factors. 2.  Address why these are risk factors. 3.  Is this patient at treatment goals for HTN?  4.  What should be the BP goal?  5.  What should the NP advice/prescribe to help the patient achieve her HTN goal?   6.  Why did you choose the treatment described in question #5?  

Ms. Gloria Briggs continued – see below her subjective and objective data points.   With findings of elevated brain natriuretic peptide and left ventricular dysfunction on echo (ejection fraction 38%), a diagnosis of HF with reduced ejection fraction (HFrEF) is confirmed. What is Gloria’s American College of Cardiology Foundation/American Heart Association (ACCF/AHA) stage and New York Heart Association (NYHA) class?   Ms. Gloria Briggs works as a librarian and presents with a 6-week history of fatigue and increasing shortness of breath. She believes that these symptoms are related to recent renovations at the library, which have reactivated her asthma; however, her nebulizer and inhaler have not relieved her symptoms. Gloria reports that her dyspnea is worse with ordinary activity and lying flat, but she is comfortable sitting. She has not experienced chest pain. She complains of her legs swelling and shoes “pinching.” She can no longer take her brisk lunchtime walk and has gained weight. Her history includes hypertension, type 2 diabetes (T2DM), and dyslipidemia; she is a nondrinker and quit smoking 7 years ago. Physical examination: o   Height: 5 ft 6 in; weight: 165 lbs. (body mass index [BMI]: 26.6 kg/m2) o   Blood pressure (treated): 140/92 mm Hg o   Heart rate: 116 bpm; respiratory rate: 22; temperature: 98.4°F o   1+ pitting edema ankles; S3 heart sound; bilateral rales at lung bases o   Mild cardiomegaly

Which is TRUE concerning Obstructive Sleep Apnea (OSA)?

Untreated Obstructive Sleep Apnea (OSA) increases the risk for other health related conditions.  List three health related conditions:    

When discussing cardio-vascular health there are several risk-enhancing factors you would want to address with your patient.  Which of the following are not considered risk enhancing ASCVD factors?     

Determine if the following statement is true or false: Don’t routinely add ezetimibe or a PCSK9 inhibitor (proprotein convertase subtilisin kexin type 9) for lower-risk-patients with CV disease, but rather help these patients manage their life-style changes and to take their statin as prescribed. 

Ms. Gloria Briggs continued – see below her subjective and objective data points. Gloria is now taking a B-blocker in addition to her other medications. What other steps might be used to treat her stage C/class II HF?   Ms. Gloria Briggs works as a librarian and presents with a 6-week history of fatigue and increasing shortness of breath. She believes that these symptoms are related to recent renovations at the library, which have reactivated her asthma; however, her nebulizer and inhaler have not relieved her symptoms. Gloria reports that her dyspnea is worse with ordinary activity and lying flat, but she is comfortable sitting. She has not experienced chest pain. She complains of her legs swelling and shoes “pinching.” She can no longer take her brisk lunchtime walk and has gained weight. Her history includes hypertension, type 2 diabetes (T2DM), and dyslipidemia; she is a nondrinker and quit smoking 7 years ago. Physical examination: o   Height: 5 ft 6 in; weight: 165 lb (body mass index [BMI]: 26.6 kg/m2) o   Blood pressure (treated): 140/92 mm Hg o   Heart rate: 116 bpm; respiratory rate: 22; temperature: 98.4°F o   1+ pitting edema ankles; S3 heart sound; bilateral rales at lung bases o   Mild cardiomegaly

John H presents to your office for his “regular physical.” He is 48 years old. In the office his initial blood pressure is 154/88 mmHg. It falls to 142/88 mmHg after ten minutes. Record review shows that his BP was 142/78 mmHg last year. His weight is 265 lbs, height 5’9″. His heart rate was 88 and regular. He has no previous diagnosis of hypertension. What of the following is the best plan for Mr. H today?