During my experience in volunteering, I chose a patient for the case study assignment. The subject I chose was identified as GKM. The patient’s chief complaint upon her visit to the clinic was for a follow-up on her hypertension and for more medication for this disease. GKM is a 56-year-old Caucasian female with the date of birth on 12-14-43.
Her past medical and surgical history consisted of childhood diseases, heart and cardiovascular problems, and cancer. The childhood diseases she had were chicken pox, mumps, and scarlet fever. Regarding to her heart and cardiovascular problems, she has had high blood pressure, ankle swelling, and dizziness. She had cervical cancer as well, which was removed by a complete hysterectomy in 1987. She has not undergone any radiation or chemotherapy. She further indicated that she has had pain in her right hip and leg, and both ankles for approximately a year. She indicated that the pain and discomfort occurs immediately after she rises from a seating position. It was concluded that she has degenerative joint disease in both knees. Also, she has osteoarthritis and had fibrocystic breast disease.
Her social history is excellent. She has never smoked, consumed alcohol, and has no known drug allergies. Her occupation was working at a Walmart warehouse for several years. Her significant family history includes cervical cancer, which she personally had, and breast cancer that her mother had. Referring to her nutrition history, she is classified as obese and has been on a non-nutritional, high fat diet. She has been consuming red meats and too much saturated fat. She is also inactive. No dental history was recorded.
The history of her present illness, hypertension, has been occurring on and off for the last year and was indicated in January 2000. She had previously visited the clinic for the same illness and the medical practitioner kept her on Diovan HCT, a diuretic. On her current visit, she complained about dizziness and how she was stressed. Her husband had a myocardial infarction 2 weeks prior to her visit and she was concerned about her blood pressure. She also had run out her prescription for Diovan HCT for hypertension, but resumed taking it the day of the exam. She also has gained excessive weight after January 2000 when she was 163 pounds. She has gained 13 pounds since then and currently weighs 176 pounds. She has had normal cholesterol, high and low-density lipoproteins, and triglycerides on her last visit. Her blood glucose has been normal.
Significant Hospital and Clinic Events
I. 1987-hysterectomy for cervical cancer
II. Jan. 25, 2000- Mammogram abnormality indicated in left breast
III. Feb. 4, 2000-Left breast biopsy done as same day surgery
IV. Feb. 20, 2000-Indicated as fibrocystic disease breast disease (benign)
VI. July 15, 2000- Indicated osteoarthritis present and degenerative joint disease.
Primary hypertension is of unknown etiology. The hemodynamic and pathophysiologic derangements are unlikely to result from a single cause. Heredity is a factor, but its exact effect is unknown. There are environmental factors such as stress, obesity, and dietary sodium that are related to hypertension. The pathogenic mechanisms lead to increased total peripheral vascular resistance by causing vasoconstriction, that thus increases cardiac output and blood pressure. Abnormal sodium transport across a cell wall due to a defect in or inhibition of the sodium-potassium pump or due to increased permeability of the sodium cation causes hypertension. As a result of increased cellular sodium cation, the sympathetic nervous system is more likely to be stimulated because of increased sensitivity. Again, this causes an increase in blood pressure. A high resting heart rate also indicates increase sympathetic nerve activity, thus a predictor of hypertension. A deficiency of a vasodilator substance may cause hypertension. The renal medulla contains vasodilators, including neutral lipid and prostaglandins. If these vasodilators are absent because of renal problems such as renal parenchymal disease, blood pressure rises. Dysfunction of nitric oxide, another vasodilator, also increases blood pressure.
GKM’s visit to the office was for a follow-up on her hypertension. The symptoms that were reported when GKM visited the office were stress, dizziness, and slight edema. The stress was due to her husband having a myocardial infarction prior to her visit. She also had gained about 13 pounds since January 2000 and was already classified as obese. Her diet consisted of non-nutritional foods and her physical activity was nonexistent. The stress, weight gain, and obesity initiated her increase in blood pressure. Her lab results indicated that her triglyceride level was 740 in November 2000, compared to 206 in January 2000. Her high-density lipoproteins had decreased from 44 to 40, and the low-density lipoproteins were invalidated due to excessive triglyceride levels. Her cholesterol increased from 190 to 235. Her blood pressure also escalated to 170/94 mm/Hg from 150/92 mm/Hg. Further, her drug levels were out of range, such as her blood urea nitrogen/creatinine ratio, which was 36H instead between 6-25 as normal. The significance of these lab results is that the excessive triglyceride levels, cholesterol, and BUN/creatinine ratio augment the hypertension she was suffering from. Due to her diet not being nutritionally dense and inactivity, the lab results were so high, especially her cholesterol because she was consuming excessive saturated fats. She is also surgically post-menopausal after her surgery and thus needs supplements of estrogen for greater calcium absorption. At the age of 56, she is likely candidate for osteoporosis. Her inactivity was probably due to her bones being weak, the fatigue she experienced when doing normal daily activities, and her past history of degenerative joint disease. Thus, this inactivity aids in increasing the triglyceride levels. Her high BUN/creatinine ratio indicates that she is having renal problems. The kidneys and especially in the glomerulus is where blood pressure is regulated due to absorption and excretion of ions, toxic wastes, water, and other components in and out of the blood. Her dizziness and perspiration was due to her stress and increased cardiac output.
Unfamiliar Medical Terminology:
I. NKDA: No Known Drug Allergies
II. RT: Radiation Therapy
III. BUN: Blood Urea Nitrogen
IV. TGA: Triglycerides
V. MI: Myocardial Infarction
VI. HCT: Hydrochlorothiazide
VII. ACE: Angiotensin Converting Enzyme
Monitoring blood pressure and observing if it is greater than 120/80 mm/Hg indicate hypertension. The medical practitioner that I worked with reviewed the patient’s medical and nutritional history first when determining diagnosis. He also took her blood pressure and had her bring in her lab results from 1 week prior to the follow-up visit. The nurse took her weight and indicated that the patient had gained weight and took her pulse, which was indicated to be high also. The prescriptions or medications that she was taking previous to her visit were noted.
The nutritional interventions usually taken to manage patients with the disease hypertension are controlling specific parameters. Primary hypertension has no cure, but treatment can modify its course. Lifestyle modifications are encouraged such as: extra rest, prolonged vacations, moderate weight reduction. Moreover, restrictions on diet aid in managing obesity, blood lipid abnormalities, and diabetes mellitus. Also, sensible exercise and physical activity should be added to one’s lifestyle or should be encouraged. Lastly, smoking should be discontinued and/discouraged. Antihypertensive drug therapy is however, more effective. Drug therapy should be initiated with a diuretic or a β-blocker, unless these drugs are contraindicated or another class of drugs is indicated. If these drugs are ineffective, alternative classes suitable for initial therapy include Ca blockers, ACE inhibitors, angiotensin II receptor blockers, α1-adrenergic blockers, and α-β-blockers. The nutrition strategies used to treat GKM were quite parallel. Overall, she was told to decrease her dietary intake and try to lose weight, to be placed on a low triglyceride diet, to relax and rest, and to take prescribed medication, a diuretic and an ACE inhibitors.
3. “Arterial Hypertension.” The Merck Manual. Merck and Co. 2000.
Name(s) of medications (generic and trade):
(1) Losartan/Hydrochlorothiazide ; Diovan HCT
(2) Gemfibrizol ; Lopid
(1) ACE inhibitor(captopril)/Diuretic
(2) Fibric Acid Derivative
Prescribed dosage: Recommended dosage: same
(1) 160/12.5 mg once a day
(2) 600 mg 2x day
Mechanism of action:
(1) Renin is a proteolytic enzyme produced and stored in the kidney. Its secretion is
regulated by the sympathetic nervous system activity and released when there is a reduction in renal perfusion pressure due to the afferent arterioles inside the glomerulus. Renin reacts with angiotensin I, a substrate formed in the liver, then is hydrolyzed to angiotensin II. Then angiotensin II acts on specific receptor sites which leads to the increase in total peripheral resistance, heart rate, and cardiac output. Thus, increases blood pressure. However, captopril blocks the conversion of angiotensin I to angiotensin II, by inhibiting the converting enzyme. It has the angiotensin-converting enzyme inhibitor which reduces the blood flow.
Thiazide diuretics block the reabsorption of sodium chloride and water in the ascending limb of the loop of Henle and early distal tubule. Thus, interfere with urinary dilation.
(2) Gemfibrizol reduces incorporation of long fatty acids into newly formed triglycerides. Thus reduces the very low-density lipoprotein production in the liver. It also controls lipoprotein lipase activity. It effects and elevates HDL cholesterol and reduces triglycerides, and LDL and VLDL cholesterol.
Nutritional Concerns (drug/nutrient interactions, patient education)
(1) Some medicines or medical conditions may interact with this medicine. This medicine should not be taken if patient is taking ketanserin. Also, monitoring may be needed if patient is taking diazoxide, digitoxin, digoxin, or lithium. Patient needs to drink lots of fluid with medication because if not, it can lead to lightheadedness and fainting. Medicine may cause increase sensitivity to sun, thus patient needs avoid exposure to the sun, sunlamps, or tanning booths. Also, no salt substitutes and potassium supplements should be taken without consulting physician. Patient should not breast feed if taking medication. If patient has diabetes, this medicine may affect your blood sugar.
(2) The patient should not stop taking this medication. The medicine may cause blurred vision or dizziness, thus it is advised that patient does not drive, operate any machinery, or do anything dangerous until effects of drug are seen. If the patient is pregnant, she should not breast feed while taking medication.
American Medical Association Dept. of Drug. Drug Evaluations. American
Medical Association : 1986.
GKM’s medical nutritional therapy was assessed with several measures. Her nutritional status is poor, with an unbalanced, non-nutritional diet and lack of exercise that has caused her obesity. Due to the obesity and no change in diet, GKM’s progress in getting better is a slow process, even though the intervention of drug therapy has been given for the past 3 months prior to her visit. She should undergo a planned low-fat, low-saturated fat diet. Moderate exercise should be a must. She must also take calcium supplements 2x a day to prevent the risk of osteoporosis and prevent some the pain she suffers when participating in her daily routine. She needs to try a monitor her blood pressure either by self-check with a home-measuring BP machine or checking at the clinic. The medical practitioner suggested the same measures, but added that she should consume minimum amounts of salt and sugars. He also suggested that she reduces her caloric intake gradually by reducing carbohydrates and fats, because sugars also turn into fat. He placed her onto a low triglyceride diet with specifics on what and what not to eat.
The medical practitioner assessed her hypertension by first suggesting being on a low triglyceride diet, specifically indicating foods to use and avoid. Also, he recommended that she reduces her caloric intake and decrease her weight with exercise. Further, estrogen supplements were suggested to be taken for the purpose of greater calcium absorption to reduce risks of osteoporosis. Lastly, he told her that the next office visit should be in three months. Also, a week prior to her visit, she should fast and have her triglyceride level, and hepatic liver function checked.
Again, the nutritional intervention is stated above. She needs to be prudent with her new diet plan. She needs to understand the effects of her obesity on her symptoms due to the hypertension. The medical practitioner clearly stated the implications of her weight gain and dietary intake that affected her physiological status. She needs to be monitored for the next year with blood pressure, cholesterol, and bone density.
The health care professional stated that the most important factor that affected her hypertension was her unhealthy diet. Her consumption of fats and red meats augmented her symptoms. In addition, her obesity and stress was a key factor in the increase of blood pressure. His assessment was strictly instructed due to her lack of nutritional practices. Thus, he placed her on a low triglyceride diet. Her past and present history of being classified as obese was also assessed with instructions to exercise. He also was concerned about her past history of bone density problems and that she was surgically post menopausal after her hysterectomy at an early age; thus, he wanted her to take estrogen supplements to reduce risks of osteoporosis and prevent recurring pain due to previously recorded osteoarthritis. Due to her ankle swelling and high blood pressure, she was kept on the diuretic, Diovan HCT. To decrease her cholesterol and triglyceride level, she was prescribed Lopid. Her social history had no significance with her assessment. Therefore, GKM’s nutritional, medical, and pharmacologic history was quite important for the medical practitioner in diagnosing his patient.