## Case #4: Laura
### Subjective Data
Laura is a 41-year-old female of Hispanic-American descent who presents to the clinic for a well-visit assessment. She reports a family history of breast cancer (mother diagnosed at 63 and cousin diagnosed at 44) and early menarche at age 10.5. Laura had her first pregnancy at 33. She is currently awaiting mammogram results. Laura’s blood pressure is 134/74, indicating borderline hypertension, and her A1c level is 6.4, placing her in the prediabetes range. She also has hyperlipidemia, which puts her at risk for cardiovascular disease.
**Additional Subjective Data Needed:**
– Detailed dietary habits and physical activity levels.
– Smoking and alcohol consumption history.
– Any symptoms of hypertension, such as headaches or dizziness.
– Any symptoms related to hyperlipidemia, such as chest pain or shortness of breath.
– Menstrual history and any abnormal bleeding.
– Breast self-exam findings or any changes in breast tissue.
– Family history of other cancers or cardiovascular diseases.
### Objective Findings
– Blood pressure: 134/74 mmHg.
– A1c level: 6.4%.
– Lipid profile: pending.
**Additional Objective Data Needed:**
– Complete lipid profile (total cholesterol, LDL, HDL, triglycerides).
– Body mass index (BMI).
– Physical examination findings, including cardiac and respiratory examination.
– Results of the pending mammogram.
– Electrocardiogram (ECG) if indicated by cardiovascular symptoms.
### Diagnostic Tests and Procedures
1. **Lipid Profile:**
– To evaluate the levels of total cholesterol, LDL, HDL, and triglycerides, as Laura has hyperlipidemia.
– **Rationale:** High levels of LDL and triglycerides are risk factors for cardiovascular disease (Grundy et al., 2019).
2. **Fasting Blood Glucose and Oral Glucose Tolerance Test:**
– To confirm the diagnosis of prediabetes and monitor glucose metabolism.
– **Rationale:** An A1c level of 6.4% suggests prediabetes, but additional glucose testing is needed for a comprehensive assessment (American Diabetes Association, 2020).
3. **Mammogram and Breast Ultrasound:**
– To screen for breast cancer, given her family history and previous early menarche.
– **Rationale:** Early detection of breast cancer significantly improves treatment outcomes (Siu, 2016).
4. **Electrocardiogram (ECG):**
– To assess for any cardiac abnormalities, given her hyperlipidemia and borderline hypertension.
– **Rationale:** Hypertension and hyperlipidemia increase the risk of cardiovascular events (Whelton et al., 2018).
### Differential Diagnoses
1. **Hypertension:**
– **Rationale:** Laura’s blood pressure is 134/74 mmHg, which falls into the high-normal range. Hypertension is defined as a consistent BP reading of ≥130/80 mmHg (Whelton et al., 2018).
2. **Prediabetes:**
– **Rationale:** An A1c level of 6.4% indicates prediabetes, which is a risk factor for developing type 2 diabetes (American Diabetes Association, 2020).
3. **Hyperlipidemia:**
– **Rationale:** Elevated cholesterol levels are indicative of hyperlipidemia, which is a major risk factor for cardiovascular disease (Grundy et al., 2019).
### Medications and Treatments
1. **Hypertension:**
– **Medication:** Lisinopril 10 mg daily.
– **Rationale:** Lisinopril is an ACE inhibitor that helps to lower blood pressure and protect the kidneys, especially in patients with diabetes or prediabetes (Whelton et al., 2018).
2. **Prediabetes:**
– **Medication:** Metformin 500 mg twice daily.
– **Rationale:** Metformin helps to improve insulin sensitivity and lower blood glucose levels. It is often used in patients with prediabetes to prevent the progression to type 2 diabetes (American Diabetes Association, 2020).
3. **Hyperlipidemia:**
– **Medication:** Atorvastatin 20 mg daily.
– **Rationale:** Atorvastatin is a statin that helps to lower LDL cholesterol levels and reduce the risk of cardiovascular disease (Grundy et al., 2019).
### Social Determinants of Health (SDoH)
– **Access to Healthcare:** Ensuring Laura has regular follow-ups and access to necessary medications.
– **Health Literacy:** Providing education on lifestyle changes to manage hypertension, prediabetes, and hyperlipidemia.
– **Cultural Factors:** Being sensitive to dietary preferences and practices common in Hispanic culture, and providing culturally appropriate education.
### Collaborative Care Referrals and Patient Education
1. **Referral to a Dietitian:**
– **Rationale:** To provide personalized dietary advice to manage prediabetes, hyperlipidemia, and support weight loss if needed (Evert et al., 2019).
2. **Referral to a Cardiologist:**
– **Rationale:** For a comprehensive cardiovascular risk assessment and management plan, considering her borderline hypertension and hyperlipidemia (Grundy et al., 2019).
3. **Patient Education:**
– **Blood Pressure Monitoring:** Teaching Laura how to monitor her blood pressure at home.
– **Lifestyle Changes:** Encouraging regular physical activity, smoking cessation if applicable, and a balanced diet rich in fruits, vegetables, and whole grains (Whelton et al., 2018).
– **Breast Health:** Educating on the importance of regular breast self-exams and understanding mammogram results.
### Follow-Up
– **Interval:** Follow up in 3 months to reassess blood pressure, A1c, and lipid profile.
– **Symptoms to Prompt Return Visit:**
– Any chest pain, shortness of breath, or unusual fatigue.
– Any changes in breast tissue or lumps.
### References
American Diabetes Association. (2020). Classification and diagnosis of diabetes: Standards of Medical Care in Diabetes-2020. Diabetes Care, 43(Supplement 1), S14-S31.
Evert, A. B., Dennison, M., Gardner, C. D., Garvey, W. T., Lau, K. H., MacLeod, J., … & Urbanski, P. (2019). Nutrition therapy for adults with diabetes or prediabetes: a consensus report. Diabetes Care, 42(5), 731-754.
Grundy, S. M., Stone, N. J., Bailey, A. L., Beam, C., Birtcher, K. K., Blumenthal, R. S., … & Yeboah, J. (2019). 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology, 73(24), 3168-3209.
Siu, A. L. (2016). Screening for breast cancer: US Preventive Services Task Force recommendation statement. Annals of Internal Medicine, 164(4), 279-296.
Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Dennison Himmelfarb, C., … & Wright, J. T. (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension, 71(6), e13-e115.
Case # (1, 2, 3 or 4) and Description of the Case Chosen:
· Case 1: Teresa
· Case 2: Joanna
· Case 3: Monica
· Case 4: Laura
Outline Subjective data.
Identify data provided in your chosen case and any additional data needed.
Outline
Objective findings.
Identify findings provided in your chosen case and any additional data needed.
Identify diagnostic tests, procedures, laboratory work indicated.
Describe the rationale for each test or intervention with supporting references.
Distinguish at least three differential diagnoses.
Describe the rationales for your choice of each diagnosis with supporting references.
Identify appropriate medications, treatments or other interventions associated with each differential diagnosis.
Describe rationales and supporting references for each.
Explain key
Social Determinants of Heath (SDoH) for your chosen case.
Describe collaborative care referrals and patient education needs for your chosen case.
Describe rationales and supporting references for each.
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