prescription and diagnosis

Using your template, please complete the prescription assignment below. Please be sure to provide references. This is an individual assignment for each student to submit independently. PATIENT: Jack Randell Address: 234 Regent Way, El Segundo, FL DOB: 05/24/67 CC: 3-month follow-up visit for re-evaluation of his blood pressure. PMH: Negative for DM, CV disease (recent hypertension), renal disease, lung disease. FMH: Dad (HTN adult years, CABG X 3 at age 55); Mom (healthy); Sister (HTN diagnosed approximately age 60). SOCIAL: 1 ppd tobacco use x (25 pack years); alcohol (social on weekends) MEDS: None. ALLERGIES: NKDA except for cats. HPI: Mr. Randell is a Caucasian male who presented to the clinic today for a 3-month follow-up visit. He had elevated blood pressure readings that were first noted 3 months ago at your office. His record revealed elevated blood pressure readings recorded at your office to be 148/90 on 3 separate clinic readings without verbalized symptoms. To date only nonpharmacological treatments have been initiated by a provider. The patient admits he had only been partially compliant with these treatment suggestions. Patient had been also instructed to keep BP journal weekly. At today’s visit, Mr. Randell reports that he has been monitoring his home blood pressures. He has been checking his BP 3 times per week compliantly, with an average and highest documented home BP reading of 160/90. Mr. Randell voices that he does not want to take medication, but he is concerned because his home BP readings appear to continue to be elevated. He is also concerned about his risk for cardiovascular disease and requests you to calculate his risk of developing cardiovascular disease. ROS: He continues to deny cardiac symptoms (chest pain/tightness/pressure, shortness of breath at rest/exertion/orthopnea/or PND, edema, dizziness/lightheadedness, syncope/near syncope, or fatigue/malaise). No vision changes. However, at this visit, he does report an occasional occipital headache. He has lost 5 pounds since his last visit to your office. Vital signs: T 98.6o, HR 82, RR 18, BP 168/92 sitting manual, O2 sat 98% room air, BMI 30. He is pleasant, cooperative and AAOx3. Well developed. Obese. Skin pink, warm, & dry, and normal for ethnicity. Gait is demonstrated as steady. Grips are equal. EKG reviewed by you and faxed to cardiology which confirms your interpretation of NSR with rate of 82 bpm, with no current signs of LVH and no acute ominous ST-T changes. Auscultation of heart demonstrates regular rhythm with apical pulse of 84 bpm, no identified heart murmur, gallop, or click (auscultated in the sitting and supine positions). No JVD. Respirations are equal and unlabored, and breath sounds are clear bilaterally. Peripheral pulses are intact/equal at 2+ (radial, popliteal, dorsalis pedis, and post tibial). Labs show total cholesterol is 240, HDL is 43, and LDL is 152, and triglycerides are 160. Your assignment will require you to: Identify Mr. Randell’s stage of HTN according to the guidelines Determine Mr. Randell’s 10-year ASCVD risk (use your American Heart Association PREVENT ASCVD calculator provided this week [slide 61]), Choose an appropriate medication regimen and provide all the information that is requested in the prescription template. NOTE: Make sure you include in your patient teaching, the patient’s calculated 10 year risk of ASCVD (see slide 61 on the PPT), and your diagnosis (including ICD10). Please closely review your APA references to ensure they are correct. Your APA manual and the Purdue OWL are excellent resources for you to check your work.