Case Study #2

Hypertension and Cardiovascular Disease

Due: March 18, 2018

Suggested Resources: http://guidelines.hypertension.ca/

PEN Hypertension Knowledge Pathway

PEN Cardiovascular Disease Pathway

Note: Canadian Guidelines for the Diagnosis and Treatment of HTN and Cardiovascular disease
are different than they are in the United States as discussed in our text. Therefore it is
important to use Canadian practice guidelines for this case study

Introduction:

Mrs. Margaret Moore is a 62 yo retired nurse. She was diagnosed 1 year ago with
hypertension. At that time she was told by her physician to change her lifestyle including diet,
smoking cessation, and exercise. Today (March 1, 2018), she is in to see her physician for
further evaluation and treatment for essential hypertension. Blood drawn 2 weeks prior to this
appointment shows an abnormal lipid profile.

The following information was collected by the physician during her visit today:

History:

Onset of disease: Mrs. Moore was diagnosed 1 year ago with essential HTN. Treatment thus
far has been focused on nonpharmacological measures. She began a walking program resulting
in a 10 lb weight loss that she has been able to maintain during the past year. She walks 30
minutes 4-5 times per week most weeks. She sometimes only manages to walk 3 times per
week when she is busy with her volunteer work. Typically she volunteers 2 to 3 times per
week. She was given a nutrition information pamphlet in the physician’s office outlining a
lower-Na diet. Mrs. Moore was a 2-pack a day smoker but quit (cold turkey) when her HTN was
diagnosed last year. No c/o of any symptoms related to HTN. Client denies chest pain, SOB,
syncope, palpitations or myocardial infarction.

Medical hx: diagnosed with thyroid disease at age 50

Surgical hx: none

Medications at home: 88mcg synthroid (1 tab/day)

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Tobacco use: no – quit 1 year ago

Alcohol use: 1 to 2 glasses of white wine/week

Family hx: Father diagnosed with HTN at age 34 and had a stroke at 52. He died at 69 d/t heart
disease. Mother diagnosed with thyroid disease at 61 and HTN at 65. She died at 84 d/t
complications related to COPD. One brother had triple bypass surgery at age 37 and died
during a heart transplant operation at 59. Second brother diagnosed with HTN at age 32.
Controlled by medication.

Demographic Information:

Marital status: Married

Number of children: 4 grown children who do not live at home
Education: MSc in Nursing
Language: English
Occupation: retired
Ethnicity: First nations living on reserve

Physical Exam:

General appearance: healthy middle-aged female who looks her age

Heart: regular rate and rhythm, normal heart sounds
Neurologic: alert and oriented
Skin: smooth, warm, dry, excellent turgor, no edema
Chest/lungs: lungs clear
Abdomen: nontender, normal bowel sounds

Vital Signs: Temp: Normal Pulse: 80 Resp rate: 15 BP: 160/100

Height: 5’6” Weight: 166 lbs

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Lab Results:

Ref. Range March 1, 2018 June 1, 2018

Chemistry
Sodium mEq/L 136-145 137 137
Potassium mEq/L 3.5-5.1 4.5 3.9
Chloride mEq/L 98-107 102 101
CO2 mEq/L 23-29 28 29
Bicarbonate mg/dL 23-28 25 26
Serum Cr mg/dL 0.6 – 1.1 (F) 0.9 1.1
Uric acid mg/d) 2.8 – 8.8 (F) 3.2 3.5
Glucose mg/dL 70-99 101 96
Inorganic Phosphate 2.2-4.6 4.1 3.5
mg/dL
Magnesium mg/dL 1.5 – 2.4 2.1 2.4
Calcium mg/dL 8.6-10.2 9.2 9.5
Osmolality 275-295 294 295
mmol/kg/H2O
Total bilirubin mg/dL < 1.2 1.1 0.9
Direct bilirubin < 0.3 0.1 0.11
mg/dL
Total protein g/dL 6-7.8 7 6.9
Albumin g/dL 3.5-5.5 4.6 4.7
Prealbumin mg/dL 18-35 32 33
Ammonia U/L 6-47 1 21
Alkaline 30-120 120 101
phosphatase U/L
ALT U/L 4-36 30 28
AST U/L 0-35 34 30
CPK U/L 30-135 (F) 100 130
Lactate 208-378 314 350
dehydrogenase U/L
Cholesterol mg/dL <200 270 210
HDLC mg/dL >59 (F) 30 38
VLDL mg/dL 7-32 30 25
LDL mg/dL <130 210 147
LDL/HDL ratio <3.22 (F) 7.0 3.9
Apo A mg/dL 80-175 (F) 75 110
Apo B mg/dL 42-120 (F) 140 115
Triglycerides mg/dL 35-135 (F) 150 125
Hematology
RBC x 108/mm3 4.2-5.4 (F) 5.3 5.25
Hgb g/dL 12-16 (F) 14.2 13.0
Hct % 37-47 (F) 45 44

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Medical Diagnosis:

The physician diagnoses elevated blood pressure and coronary heart disease. The physician
initiates pharmacologic therapy with Hydrochlorothiazide (1-25 mg tab/day) and Coversyl
(Perindopril erbumine) 1-4 mg tab/day and reinforces of lifestyle modifications.

The physician refers Mrs. Moore to the dietitian for nutritional assessment and treatment.

…………………………………………………………………………………………………………………………………………………

The outpatient dietitian meets with Mrs. Moore the next day and conducts a dietary
assessment. The dietitian also has access to the physician’s records.

Nutrition: Mrs. Moore describes her appetite as “very good.” She does the majority of grocery
shopping and cooking, although Mr. Moore cooks breakfast on the weekends. She usually eats
3 meals per day, but on her volunteer nights, she may skip dinner. When she does this, she is
really hungry when she gets home in the late evening, so she often eats a bowl of ice cream
before going to bed. The Moores usually eat out on Friday and Saturday evenings at pizza
restaurants or steakhouses. Mrs. Moore usually has 2 glasses of white wine with these meals.
She mentions that last year when her HTN was diagnosed, the physician’s office gave her a
sheet of paper with a list of foods to avoid for a lower-salt diet. She states that she certainly is
familiar with a low-salt diet from when she practiced as a nurse. She and her husband tried to
comply with the diet guidelines but they found foods bland and tasteless, and they soon
abandoned the effort.

24-hour recall:

Breakfast: 1 cup black coffee

Oatmeal (I instant package with 1 tsp margarine and 2 tsp sugar)
I cup orange juice
Snack: 2 cups black coffee
1 glazed donut
Lunch: 1 can tomato soup prepared with whole milk (1:1 mixture)
10 salted crackers
1 can diet cola
Supper: 6 oz baked chicken, no skin, white meat, seasoned with salt, pepper & garlic salt
1 large baked potato with 1 tbsp butter, salt and pepper
1 cup glazed carrots (1 tsp sugar, 1 tsp butter)
2 cups tossed salad with 3 tbsp ranch dressing (regular)
1-8oz glass of white wine
Snack: 2 cups buttered popcorn

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Food allergies/intolerances: none
Food purchase/preparation: Self and husband
Supplement intake: Women’s multivitamin and mineral supplement daily
Co-enzyme Q10 for her heart
Tumeric to reduce inflammation

The dietitian arranges to follow up with Mrs. Moore 3 months later for monitoring and
evaluation and requests lab values for that appointment.

Case Questions:

Understanding the Disease and Pathophysiogy

1. Define arterial blood pressure and explain how it is measured (2 marks).

2. Briefly discuss the mechanisms that regulate arterial blood pressure including the
sympathetic nervous system, the renin-angiotensin-aldosterone system and renal
function. (6 marks)

3. What is essential hypertension? (1 mark)

4. What are the common symptoms of essential hypertension? (1 mark)

5. Using the latest guidelines from Hypertension Canada (see resource above), discuss how
the diagnosis of hypertension is made. (4 marks)

6. List the risk factors for developing hypertension. What risk factors does Mrs. Moore
currently have? (5 marks)

7. What factors found in the medical and social history are pertinent for determining Mrs.
Moore’s coronary heart disease (CHD) risk category? (5 marks)

Understanding the Nutrition Therapy

8. The dietitian decides to try to motivate Mrs. Moore to follow the DASH diet. Briefly
describe this diet and discuss the major nutrients that are components of this nutrition
therapy. (5 marks)

9. What does the current literature and PEN indicate regarding the role of sodium intake in
the control of hypertension? Is there a significant correlation between sodium intake
and cardiovascular risk? (5 marks)

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Nutritional Assessment

10. Using the available data, assess Mrs. Moore’s nutritional status (don’t forget to compare
your results to current nutrition recommendations for individual’s with hypertension
and who are at risk for coronary heart disease). (10 marks)

11. Go to http://cvdrisk.nhlbi.nih.gov/. Using this online calculator, determine Mrs.

Moore’s risk of cardiovascular disease based on her lipid profile. (3 marks)

12. How do Mrs. Moore’s labs change between her ‘today’s results’ and 6 months later.
What factors in her history may have made an impact on these (ie; explain the
changes)? (2 mark)

13. Are there any drug-nutrient interactions that Mrs. Moore needs to consider? Please
explain the role of each of the prescribed medications and any impact they may have on
Mrs. Moore’s nutritional status. (5 marks)

14. From the information gathered and your assessment and interpretation of Mrs. Moore’s
nutritional status, list all possible nutrition problems. (5 marks)

Nutrition Diagnosis

15. Select the two most important nutrition problems and complete PES statements for
each. (4 marks)

Nutrition Intervention

16. Write a nutrition prescription for Mrs. Moore. For each of the PES statements that you
have written establish a goal based on the signs and symptoms and an appropriate
intervention based on the etiology. (5 marks)

Monitoring and Evaluation

17. Besides the lab values, what would you want to monitor and evaluate at Mrs. Moore’s
next follow-up appointment? (2 marks)

Total Value: 70

Actual Value: /15