Cardiology/Endocrine Case Study

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 8-) 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)-