Mrs. Lyons is a 57-year-old African American female who recently developed headaches and had an elevated blood pressure reading at her work health fair. Her blood pressure was taken at the health fair, and the reading was 168/99. She has returned to the drugstore three times to take her blood pressure. The readings have been: 145/90, 150/89, 140/88. At the health fair, she was told her BMI is elevated. Her cholesterol levels were also done at the health fair, and the results were: total cholesterol level of 250, LDL 138, HDL 48, and Triglycerides 170.  

She has not been to see a primary care provider in over 5 years. At her last office visit, which was 5 years ago, her blood pressure was (135/95). Her LDL and triglycerides were also elevated at that time. The patient was supposed to monitor her blood pressure at home and trial diet and lifestyle changes. She was supposed to return for a follow-up with her blood pressure log and for a recheck of her labs. She, unfortunately, did not do this. 

Today in the clinic, her vital signs are: BP 146/92, HR 90, Temp 98.4, RR 12, O2 98%, Height 5’5, Weight 220 lbs, BMI 36.6 

She is not currently taking any medications. She has NKDA. Family history: her brother and sister both have been diagnosed with hypertension and DM. Diagnoses for the patient are HTN, Obesity, and Hyperlipidemia. 

Q1. Please briefly discuss the first-line treatment recommendations from JNC8, and the AHA/ACC for a patient with no other major comorbidities. 

Q2. What are the recommended medications to start this specific patient on? Please provide the drug class, generic & trade name, and initial starting dose. 

Q3. Please discuss the mechanism of action of each of the drugs you listed.

Q4.  Please discuss the side effect profile of each medication you listed. 

Q5. Are there any interactions between any of the medications you prescribed?

Q6. What other non-pharmacological interventions would be suggested?

1. 500 words 

Post your answers to the 6 questions corresponding to this week’s content on primary care medication management. Provide your responses and rationales. Support your rationales with high-level evidence. (See Post Expectations) 

A 70-year-old woman is in your office complaining of recently having trouble maintaining her balance after taking diazepam (valium). She occasionally takes diazepam when she feels anxious and has trouble sleeping. She has a 15-year history of taking diazepam. • Q1. Explain the cause of this patient’s difficulty in maintaining her balance? 

• Q2. Diazepam experiences a significant first-pass effect. What is the first-pass effect, and how can first-pass metabolism be circumvented? 

A 75-year-old woman develops symptoms of a cold and buys an over-the-counter cold medication at the grocery store. The medication contains diphenhydramine, acetaminophen, and phenylephrine. She takes the recommended adult dose but soon after taking the medication, she becomes very confused and disoriented. 

• Q3. What is likely causing the signs of confusion? 

 A 26-year-old woman who has never been pregnant is seeking preconception care as she is planning to pursue pregnancy in a couple of months. Currently, she has no symptoms to report and on review of body systems, there were no concerns. Her past medical history is significant for a history of rheumatic fever as a child. She subsequently underwent valve replacement with a mechanical heart valve. She is followed by a cardiologist who has already evaluated her cardiac function and she has received clearance from her cardiologist to pursue pregnancy. Records from her cardiologist include a recent cardiac echocardiography report that reveals a normal ejection fraction indicating normal cardiac function.

  She has no alterations in her daily activities related to her heart. She has no other significant medical or surgical history. She is a non-smoker, drinks occasionally but has stopped as she is attempting to conceive, and does not use any non-prescription drugs. Current Medications: Her current medications include only prenatal vitamins, which she has begun in anticipation of pregnancy, and warfarin. She has no known drug allergies.  Vital Signs: On examination, her pulse is 80 beats per minute, blood pressure is 115/70 mm Hg, respiratory rate is 18 breaths per minute, and she is afebrile. Measurements: Weight = 152 pounds, Height = 5′5 ″, BMI= 25.29 

• Q4. How is warfarin metabolized? Does warfarin cross the placental barrier? 

• Q5. Explain the hepatic drug metabolism of children 1 year and older. How do they compare with the hepatic drug metabolism of infants and adults?

ʉۢ Q6. Explain protein binding in the neonate.

A 20-year-old female presents with severe migraines.  She has been treated for the last two years. • What is the pathophysiology involved with the prodrome associated with migraines? • Compare and contrast tension headache and cluster headache.  Use patho principles. • What is the pathophysiologic difference between migraine headache and tension headache?

1. 250 words, no need for cover page. At least 2 references, APA, less than 5 years. 

A  47-year-old female presents with Stage IV breast cancer.  Today, the PET scan reveals brain metastasis.

1. Define proliferation and differentiation and relate these changes to cancer.
2. Describe invasion, angiogenesis and metastasis.
3. There are three underlying causes of growth and maturity abnormalities: telomerase, pRB changes and 53 changes.  Discuss these in relation to the patient. 
4. Discuss tumor suppressor genes, oncogenes and DNA repair genes.

250 words , no need for cover page