13 May Emiliano Jiménez, a 55-year-old male client (DOB: 9/27/1969), presents to the clinic for a follow-up appointment after he was hospitalized last week for an MI with stent placement and started on aspirin, clopidogrel, and atorvastatin
CASE STUDY:
Emiliano Jiménez, a 55-year-old male client (DOB: 9/27/1969), presents to the clinic for a follow-up appointment after he was hospitalized last week for an MI with stent placement and started on aspirin, clopidogrel, and atorvastatin. His lab work from the hospital indicated elevated LDL cholesterol levels, a hemoglobin A1c of 7%, and normal kidney function. The NP performs a physical assessment, which indicates the PCI access site is healing, there is no evidence of hematoma or bleeding, and the rest of the physical exam is otherwise normal. The NP considers the need for additional medications given the client’s new diagnoses of high cholesterol, MI, and CAD.
Past Medical History: High Cholesterol, Coronary Artery Disease (CAD), MI with stent placement, Type 2 Diabetes
Allergies: Penicillin
Medications: metformin (Glucophage) 500mg PO BID, aspirin 81mg PO daily, atorvastatin (Lipitor) 40mg PO daily, clopidogrel (Plavix) 75mg PO daily
Social History: He quit smoking cigarettes 25 years ago and drinks alcohol once every six months on special occasions.
Physical Exam:
• Height: 5 feet 9 inches
• Weight: 205 lbs
• Body Mass Index (BMI): 30.3
• Blood Pressure (BP): 121/75
• Heart Rate (HR): 82
• Respiratory Rate (RR): 18
• Oxygen Saturation (O2 Sat): 97% on RA
• Temperature (TEMP): 98.7 oral
Step 1: Assess the client’s case, the applicable clinical practice guideline (CPG), and the prescription writing activity for that client within the lesson.
Step 2: Answer the discussion prompts below with explanation and detail, providing complete references for all citations. Refer to the lesson for client information.
1. Application of Course Knowledge: Answer all questions/criteria with explanations and detail.
a. Describe your assigned client’s situation. Why are they presenting to the clinic? What medications are they currently taking?
b. Assess the applicable clinical practice guideline (CPG) for your assigned client linked on the same page in the lesson where the client case is located. What treatment is recommended by the CPG for your client’s situation?
c. Discuss your personal professional assessment of the client’s situation provided in the scenario. What pharmacological treatment is necessary and why?
d. Reflect on additional questions you have about your assigned client that may influence treatment. What else do you need to know? What follow-up assessments, labs, or conversations are required to ensure optimal health outcomes?
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