RESPONSE 1:
As part of the treatment plan, Janice is receiving medication of Lisinopril of 20mg every day, an angiotensin-converting enzyme used for high blood pressure and heart failure treatment in patients. She is also receiving the Norvasc which is a calcium channel blocker for treating high levels of blood pressure in patients, and she takes 10mg per day. She is also on medication of metformin which treats the diabetes of type 2 which causes increase in blood sugar levels in patients where she takes 1000 mg daily. I find that the treatment plan for Janice may not be optimal because the medication taken does not reduce the high blood pressure but instead, the patient’s blood pressure is still high at 150/90. The cholesterol levels are still high, with 360 and LDL at 220, which means the patient is at risk of a heart attack.
I would like to obtain information about the type of diabetes the patient may be suffering from and determine if it is either type 1 or 2 diabetes. This would help in getting a better treatment plan for the patient. In addition, I would be concerned to know of the changes that have taken place in the patient’s life. Understanding the lifestyle changes would help develop a lifestyle intervention that would help treat the patient.
Most patient with HTN and diabetes requires a combination therapy that would help them attain a 130/80 mm Hg blood pressure or even less (Knott, 2020). In addition, anti-hypersensitive medication should also be used. The patient’s lifestyle therapy would include reducing the body weight, increasing consumption of vegetables and fruits, caloric restrictions, increasing physical activities, and reducing sodium intake. In addition, the patient should take ACE inhibitors and a diuretic (De Boer et al., 2017). A single pill combination of a perindopril, an ACE inhibitor, and indapamide, a diuretic, would help lower the blood pressure level to 130/90 mm Hg.
RESPONSE 2:
Testosterone is the primary male hormone responsible for regulating sex differentiation, producing male sex characteristics, spermatogenesis, and fertility (Nassar & Leslie, 2021). Testosterone generally peaks during adolescence and early adulthood. After which, levels gradually decline by approximately 1% a year after age 30 or 40 (Mayo Clinic, 2020). Some of the characteristics regulated by testosterone include male hair patterns, vocal changes/deepening, anabolic effects such as growth spurts, and skeletal muscle growth, even stimulating erythropoiesis resulting in higher hematocrit counts as compared to females (Nassar & Leslie, 2021). In puberty, the hypothalamus secretes gonadotropin releasing hormones (GnRH), which travels down the hypothalamohypophyseal portal system to the anterior pituitary, which secretes luteinizing hormones (LH) and follicle-stimulating hormones (FSH) (Nassar & Leslie, 2021). LH acts on the Leydig cells to increase testosterone production while FSH helps to control the production of sperm. Testosterone limits its secretion through a negative feedback loop which means that high levels feed back to the hypothalamus to suppress secretion of GnRH and to the anterior pituitary, to make it less responsive to the GnRH stimuli (Nassar & Leslie, 2021).
Based on Darrens lab results, it looks like his testosterone level is lower than normal, which could potentially be due to aging, or an array of other causes to include trauma, medications, chemotherapy, and genetic disorders, among others, causing primary or secondary hypogonadism (Cleveland Clinic, 2018). Hypogonadism can be either primary, wherein there is not enough testosterone in the body as a result of a problem with the sex gland or the testicles, or secondary, wherein the problem lies with the hypothalamus or pituitary glands which are responsible for sending signals to the gonads (Nassar & Leslie, 2021). Low testosterone is manifested by decreased libido, erectile dysfunction, depressed mood, fatigue, irritability, increased body fat, muscle loss, gynecomastia, osteoporosis, as well as hot flashes, and among these, his symptoms of lack of energy, weight gain, and decreased erections are included (Cleveland Clinic, 2018). To determine the cause of hypogonadism, Nassar & Leslie (2021) mention that it is prudent for providers to not only to get a good H&P, but also to order labs such as total serum testosterone between 8AM and 10AM. They added that if levels are low, a repeat draw should be done along with FSH and LH levels. They further stated that low testosterone in the setting of normal FSH and LH indicates secondary hypogonadism, whereas low testosterone with elevated FSH and LH indicates primary hypogonadism. With secondary hypogonadism, the next steps would be to get prolactin, T4, 8AM cortisol, iron, and ferritin levels, as well to get a brain MRI to determine underlying cause. For primary hypogonadism, it is probably a good idea to order a karyotype to determine genetic cause (Nassir & Leslie, 2021).
In sorting through his current medications, the other possibility I noted that may contribute to one of his concerns is that Niacin deficiency can also cause extreme tiredness (NIH Office of Dietary Supplements, 2021), so maybe her vitamin B3 levels may need to be checked and diet reviewed to ensure she is taking enough, but if not, then maybe it is worth checking her lipid levels as well to see if uptitrating the dosage may be appropriate. On another note, antihypertensives such as thiazide diuretics have been reported to have an occasional side effect of erectile dysfunction because such medications can cause decreased blood flow to the penis. Therefore, if Darren is concerned about ED, he should bring this up to his provider to see if there is an appropriate substitute for lisinopril/HCTZ (Solan, 2017).
Testosterone replacement therapy (TRT) is used to treat low testosterone levels which can be given in several ways such as IM injections, testosterone patches, testosterone gels, and pellets (Cleveland Clinic, 2018). Based on the information provided, Darren will be a good candidate for TRT. However, it is important that even though his PSA levels are normal now, it should be monitored frequently as TRT can increase PSA levels and additionally undergo periodic prostate cancer screening to ensure that there is no other reason for the elevation of PSA (Cleveland Clinic, 2018). Those who should not take TRT are those who already have enlarged prostate causing symptoms, lump on their prostate that has not been evaluated yet, PSA level above 4, breast cancer, elevated Hct level as TRT can increase Hct levels making a person prone to thrombosis, severe CHF as TRT can cause mild fluid retention, and untreated OSA (Cleveland Clinic, 2018).
