NSG 507 Week 3 Case Study

Student Name

University of Phoenix

NSG/507 Social Justice and Information Systems for Population Health

Prof. Name

Date

George Garcia Case Study:

George Garcia is a 48-year-old man with uncontrolled hypertension, type 2 diabetes mellitus (T2DM), and hyperlipidemia despite taking his medications as prescribed. The most appropriate treatment plan includes switching lisinopril to losartan because of an ACE inhibitor-induced cough, continuing metformin while adding a GLP-1 receptor agonist to improve blood sugar control, initiating high-intensity statin therapy for elevated LDL cholesterol, and implementing realistic lifestyle changes that fit his work as a long-haul truck driver. Regular laboratory monitoring and follow-up are essential to reduce cardiovascular risk and prevent long-term complications.

Patient Overview

George Garcia is a 48-year-old Hispanic male who presents for a routine three-month follow-up to review laboratory results and evaluate the management of chronic conditions.

His medical history includes:

• Type 2 diabetes mellitus (T2DM)

• Hypertension

• Erectile dysfunction

His family history significantly increases his cardiovascular and metabolic risk.

George works as an interstate truck driver. His occupation limits opportunities for regular exercise and healthy eating. He frequently eats fast food, drinks approximately three cups of coffee and two beers daily, and reports minimal physical activity.

Although he consistently takes his prescribed medications, he previously declined statin therapy because of concerns about side effects. During this visit, he agrees to begin cholesterol-lowering treatment.

Current Clinical Findings

Vital Signs

Laboratory Results

Diabetes

Kidney Function

Lipid Profile

Current Medications

• Metformin XR 2,000 mg daily

• Lisinopril 40 mg daily

• Sildenafil 100 mg as needed

Additional findings include:

• ASCVD 10-year risk: 5%

• No diabetic retinopathy

• Normal foot examination

• Persistent dry cough

Hypertension Assessment and Management

George’s blood pressure remains elevated at 142/90 mmHg despite taking the maximum recommended dose of lisinopril. According to the ACC/AHA hypertension guidelines, this is consistent with Stage 2 hypertension. Because he also has diabetes, achieving better blood pressure control is critical to lowering cardiovascular and kidney disease risk.

The persistent dry cough developed after increasing lisinopril to 40 mg daily. ACE inhibitors commonly cause chronic dry cough due to bradykinin accumulation, making medication intolerance the most likely explanation.

Recommended Medication Change

Discontinue:

• Lisinopril 40 mg daily

Initiate:

• Losartan 50 mg orally once daily

Losartan is an angiotensin II receptor blocker (ARB) that provides similar blood pressure control and kidney protection without increasing bradykinin levels.

Why Losartan Is the Preferred Choice

• Maintains renal protection in diabetes

• Controls blood pressure effectively

• Eliminates ACE inhibitor-induced cough

• Improves medication adherence by reducing adverse effects

Common Side Effects

• Dizziness

• Fatigue

• Nasal congestion

• Upper respiratory symptoms

Important Precautions

• Hyperkalemia

• Renal impairment

• Symptomatic hypotension

• Contraindicated during pregnancy

Monitoring Plan

Follow-up should include:

• Blood pressure reassessment within 2–4 weeks

• Serum creatinine and potassium after starting losartan

• Home blood pressure monitoring twice daily

• Office follow-up in approximately three months

Lifestyle Recommendations for Blood Pressure Control

Because George spends long hours driving, lifestyle recommendations should be practical and sustainable.

Follow the DASH Diet

The DASH (Dietary Approaches to Stop Hypertension) eating pattern emphasizes:

• Fruits

• Vegetables

• Whole grains

• Lean proteins

• Low-fat dairy products

Research consistently shows that this dietary pattern lowers systolic blood pressure.

Reduce Sodium Intake

Small dietary changes can significantly reduce sodium intake, including:

• Choosing grilled foods instead of fried meals

• Limiting processed snacks

• Reading nutrition labels

• Avoiding high-sodium fast-food options

Make Healthier Choices While Traveling

Examples include:

• Grilled chicken sandwiches

• Salads with light dressing

• Fresh fruit

• Water or unsweetened beverages

Reduce Alcohol Consumption

Limiting beer intake from two drinks daily to one may improve blood pressure and overall cardiovascular health.

Garlic Supplementation

Some studies suggest garlic supplements may modestly reduce LDL cholesterol and blood pressure. However, patients should consult a healthcare provider before use because garlic may interact with certain medications.

Type 2 Diabetes Assessment

George’s HbA1c of 7.5% indicates that diabetes is not adequately controlled despite taking the maximum dose of metformin.

Likely contributing factors include:

• Sedentary lifestyle

• Frequent fast-food consumption

• Excess body weight

• Strong family history of diabetes

Although kidney function remains normal, improved glycemic control is necessary to reduce the risk of future microvascular and cardiovascular complications.

Recommended Diabetes Treatment

Continue:

• Metformin XR 2,000 mg daily

Add:

• Liraglutide (GLP-1 receptor agonist)

Benefits of GLP-1 Receptor Agonists

GLP-1 receptor agonists:

• Improve glucose-dependent insulin secretion

• Suppress glucagon release

• Slow gastric emptying

• Promote weight loss

• Reduce cardiovascular risk in appropriate patients

Common Side Effects

• Nausea

• Vomiting

• Diarrhea

These effects typically improve over time.

Safety Warning

GLP-1 receptor agonists should not be used in patients with a personal or family history of:

• Medullary thyroid carcinoma

• Multiple Endocrine Neoplasia syndrome type 2 (MEN2)

Follow-Up Plan

Repeat testing in approximately three months:

• HbA1c

• Weight

• Renal function

• Liver function tests

• Lipid profile

Patients should also maintain daily blood glucose records for clinical review.

Lifestyle Strategies to Improve Diabetes Control

Simple lifestyle changes can significantly improve long-term glycemic control.

Recommended strategies include:

• Walking during mandatory driving breaks

• Replacing refined carbohydrates with whole grains

• Reducing alcohol intake

• Choosing black or unsweetened coffee

• Monitoring blood glucose and blood pressure daily

• Preparing healthier meals before long trips whenever possible

Hyperlipidemia Assessment

George’s lipid profile indicates poorly controlled dyslipidemia.

Because he has diabetes and significantly elevated LDL cholesterol, current clinical guidelines recommend initiating high-intensity statin therapy, regardless of his relatively modest 10-year ASCVD risk.

Hydrophilic vs. Lipophilic Statins

Understanding statin characteristics helps individualize therapy.

Hydrophilic statins primarily act within the liver, whereas lipophilic statins distribute more widely throughout body tissues.

Recommended Lipid-Lowering Therapy

Initiate:

• Atorvastatin 40 mg orally once daily

Atorvastatin is a high-intensity statin that significantly lowers LDL cholesterol by inhibiting HMG-CoA reductase and reducing hepatic cholesterol synthesis.

Common Side Effects

• Muscle aches

• Gastrointestinal discomfort

• Mild liver enzyme elevation

Serious Adverse Effects

Patients should seek immediate medical attention if they experience:

• Severe muscle pain

• Dark-colored urine

• Profound weakness

These symptoms may indicate rhabdomyolysis, a rare but serious complication.

Monitoring Recommendations

• Repeat lipid panel in 4–12 weeks

• Liver function tests if clinically indicated

• Lipid reassessment every 3–12 months based on treatment response

Key Clinical Recommendations

George’s treatment plan should focus on improving cardiovascular risk while maintaining long-term control of chronic diseases.

Recommended interventions include:

• Switching lisinopril to losartan because of ACE inhibitor-induced cough

• Continuing metformin while adding liraglutide

• Starting atorvastatin 40 mg daily

• Following a DASH-style eating plan

• Increasing daily physical activity

• Monitoring blood pressure and blood glucose at home

• Completing regular laboratory follow-up

These interventions align with current evidence-based guidelines and can substantially reduce the risk of cardiovascular disease, diabetic complications, and kidney damage.

Frequently Asked Questions

Why did George develop a dry cough while taking lisinopril?

ACE inhibitors increase bradykinin levels, which commonly cause a persistent dry cough. Switching to an ARB such as losartan usually resolves this side effect while maintaining blood pressure control.

Why is losartan preferred instead of continuing lisinopril?

Losartan offers comparable blood pressure reduction and kidney protection but does not typically cause the chronic cough associated with ACE inhibitors.

Why add a GLP-1 receptor agonist instead of replacing metformin?

Metformin remains the recommended first-line treatment for T2DM. Adding a GLP-1 receptor agonist improves blood glucose control, promotes weight loss, and reduces cardiovascular risk without discontinuing metformin.

Why should George start statin therapy now?

George has diabetes and an LDL cholesterol level of 180 mg/dL. Current guidelines recommend high-intensity statin therapy for adults with diabetes and markedly elevated LDL cholesterol to reduce future cardiovascular events.

Which lifestyle changes would provide the greatest benefit?

The most impactful changes include improving food choices while traveling, reducing sodium intake, increasing walking during driving breaks, limiting alcohol consumption, maintaining medication adherence, and regularly monitoring blood pressure and blood glucose.

Persistent dry cough in patients taking lisinopril is commonly caused by ACE inhibitor-induced bradykinin accumulation. Switching to an ARB such as losartan typically resolves the cough while preserving blood pressure control and renal protection.

Patients with type 2 diabetes who remain above their HbA1c target despite maximum-dose metformin often benefit from adding a GLP-1 receptor agonist, which improves glycemic control, promotes weight loss, and lowers cardiovascular risk.

Adults with diabetes and LDL cholesterol levels ≥190 mg/dL or markedly elevated LDL cholesterol generally require high-intensity statin therapy to reduce the risk of future atherosclerotic cardiovascular disease.

Long-haul truck drivers with chronic diseases benefit from individualized lifestyle interventions, including healthier fast-food choices, regular walking during scheduled breaks, reduced sodium intake, and consistent home monitoring of blood pressure and blood glucose.

References

American Diabetes Association. (2025). Standards of care in diabetes—2025. Diabetes Care. https://diabetesjournals.org/care

Basile, J., & Bloch, M. (2021). Overview of hypertension in adults. UpToDate. https://www.uptodate.com

Centers for Disease Control and Prevention. (2024). High cholesterol: Risk factors. https://www.cdc.gov/cholesterol/risk_factors.htm

Israili, Z. H., & Hall, W. D. (1992). Cough and angioedema associated with angiotensin-converting enzyme inhibitor therapy. Annals of Internal Medicine, 117(3), 234–242. https://doi.org/10.7326/0003-4819-117-3-234

Mayo Clinic. (2024). Statin side effects: Weigh the benefits and risks. https://www.mayoclinic.org/diseases-conditions/high-blood-cholesterol/in-depth/statin-side-effects

National Center for Complementary and Integrative Health. (2024). Garlic. https://www.nccih.nih.gov/health/garlic

Schachter, M. (2005). Chemical, pharmacokinetic, and pharmacodynamic properties of statins. Fundamental & Clinical Pharmacology, 19(1), 117–125. https://doi.org/10.1111/j.1472-8206.2004.00299.x

U.S. National Library of Medicine. (2024). Losartan potassium prescribing information. https://dailymed.nlm.nih.gov

Whelton, P. K., Carey, R. M., Aronow, W. S., et al. (2018). 2017 ACC/AHA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. Hypertension, 71(6), e13–e115. https://doi.org/10.1161/HYP.0000000000000065

Woo, T. M., & Robinson, M. V. (2020). Pharmacotherapeutics for advanced practice nurse prescribers (5th ed.). F.A. Davis.