First, focus on the patient’s most acute pulmonary symptomatology would be necessary to provide appropriate care. The patient has a new diagnosis of chronic bronchitis, meaning that she has been experiencing a cough for at least three consecutive months, but potentially for longer periods. Because the patient has received the official diagnosis of chronic bronchitis, we would assume that the prior physician performed a chest x-ray, sputum collection, and possibly pulmonary function testing in order to rule out other causes of lung disease, such as infection. However, if this testing cannot be confirms as having occurred, it is necessary to repeat testing. Assuming that the patient has isolated chronic bronchitis, appropriate care would involve antitussive agents or medicated, anti-inflammatory inhalers (Bronchitis, 2017). However, this patient clearly has signs of heart failure which would complicate her care.
The patient is likely presenting with congestive heart failure, supported by her symptoms of peripheral edema and distension of neck veins. Her heart failure is most likely due to a common pathophysiologic mechanism which often begins with uncontrolled hypertension. Because of hypertension, the left ventricle of the heart is required to increase total muscular workload in order to provide sustained cardiac output, leading to hypertrophy of the left-ventricular muscle wall. This process is also called systolic cardiac dysfunction or systolic heart failure. Due to increased back pressure on the left heart due to systemic increases in blood pressure, the patient will experience congestion of the heart, first increasing blood backup in the left atrium, then extending into congestion of the pulmonary vasculature. With disease progression, the inability of the left heart to eject blood efficiently will lead to congestion into the right ventricle and atria. At this point in the disease, congestion becomes visible evident on physical exam with the presence of jugular venous distension, as the jugular vein directly empties into the right atria. Continued congestion of the cardiovascular system will them become evident due to peripheral edema and pulmonary edema, leading to end-organ failure (Congestive, 2014).
The next stage of patient care involves the analysis of the patient’s hypertension and relative lack of control. Based on the single blood pressure value of 158/98 mmHg, it is possible to state the patient currently experiences stage 2 hypertension. However, confirmation of the diagnosis requires serial blood pressure measurement with sustained values at or higher than 140/90 mmHg. In this patient, who is young and diabetic, goal blood pressure measurement should be less than 140/90 mmHg. As this patient has hypertension without hypertensive urgency or emergency, it would have been appropriate for a physician to place the patient on a single ACE-inhibitor, Lotensin, and a loop diuretic, Lasix. However, the patient has continued to have hypertension along with signs of fluid overload. As hypotensive episodes are potentially dangerous to patients, it is important to incrementally add anti-hypertensive agents rather than adding multiple drugs at one time.
The most appropriate first step for this patient’s medical regimen would involve addressing her hypertension through fluid overload. Importantly, the patient should be directed to move her Lasix dose to a morning and mid-day administration only in order to avoid her current side effect of nocturia. Additionally, the dosage of Lasix should be increased, assuming the current dose is not yet at the maximum recommended level. Following this change in care, the patient should be scheduled for a follow-up appointment in one month. If the patient still fails to reach blood pressure goals, her dose of ACE inhibitor should either be increased or a second antihypertensive agent should be added. This process of follow-up and reevaluation should be continued until adequate control is achieved. However, it should also be concluded that the current ACE inhibitor usage is not the cause of the patient’s cough. If cough onset corresponds to the initiation of ACE inhibitor administration, the patient should be taken off of Lotensin and put on a different class of antihypertensive agent (High, 2018; Gupta, 2010).
In regards to the other lab work obtained on this patient, it is clear that her cholesterol levels and triglycerides are not ideal. The first step of care should involve administration of daily statin therapy. Triglyceride levels should not be independently treated initially, instead recommending a follow-up lipid panel after statin use and with an understanding of fasting lab draws. Without proper treatment of lipids, this patient is at significantly increased risk for large and small vessel disease with the increased likelihood of an atherosclerotic adverse cardiac event. Additionally, the patient’s HbA1c of 7.3% (greater than the maximum 6.5%) suggests that blood glucose control could be improved. This may be accomplished with increased metformin dosages or addition of other anti-diabetic medications, such as GLP1, SGLT2, or DPP4 inhibitors. Insulin injection is not yet merited for the care of this patient. Uncontrolled diabetes can also result in renal damage, which may or may not be responsible for the patient’s increased hematocrit and continued hypertension.
Overall, the patient should receive follow-up and repeat lab values in 1 month (with HbA1c performed every 3 months) in order to check the effectiveness of new statin therapy, increased Lasix dose, and increase metformin dose. Follow-up and medication alteration should continue until all disease states are controlled. Finally, the patient should receive annual eye exams, checking for diabetic retinopathy, along with annual testing of distal sensation and monthly kidney function panels (Hogan, 2014).