NSG 507 Week 3 Case Study

Student Name

University of Phoenix

NSG/507 Social Justice and Information Systems for Population Health

Prof. Name:

Date

A Comprehensive Case Study of George Garcia

George Garcia is a 48-year-old Hispanic male with uncontrolled hypertension, type 2 diabetes mellitus (T2DM), and hyperlipidemia despite medication adherence. His persistent hypertension, elevated HbA1c, and significantly abnormal lipid profile indicate the need for medication optimization, lifestyle modifications tailored to his occupation, and regular monitoring. The most appropriate management includes replacing lisinopril with losartan due to an ACE inhibitor-induced cough, intensifying diabetes therapy with a GLP-1 receptor agonist while continuing metformin, initiating high-intensity statin therapy, and implementing practical dietary and behavioral interventions suitable for a long-haul truck driver.

Patient Overview

George Garcia is a long-term patient presenting for his routine three-month follow-up appointment to review laboratory results related to Type 2 Diabetes Mellitus (T2DM).

His medical history includes:

Type 2 diabetes mellitus
Hypertension
Erectile dysfunction

His family history is significant for:

Father: Type 2 diabetes and myocardial infarction
Mother: Type 2 diabetes and obesity
Two sisters with obesity

George works as an interstate truck driver, making regular exercise and healthy eating difficult. He frequently consumes 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 regarding adverse effects. During this visit, however, he expresses willingness to begin cholesterol-lowering medication.

Current Clinical Findings

Vital Signs

Blood pressure: 142/90 mmHg
Pulse: 82 beats/min
Respiratory rate: 20 breaths/min
BMI: 28 kg/m² (overweight)

Laboratory Results

Diabetes

HbA1c: 7.5%
Fasting glucose: 116 mg/dL

Kidney Function

eGFR: 110 mL/min
Creatinine: 0.9 mg/dL
Urine albumin-to-creatinine ratio: Normal

Lipid Profile

Total cholesterol: 235 mg/dL
LDL cholesterol: 180 mg/dL
HDL cholesterol: 32 mg/dL
Triglycerides: 190 mg/dL

Current Medications

Metformin XR 2,000 mg daily
Lisinopril 40 mg daily
Sildenafil 100 mg as needed

Additional Assessment

ASCVD 10-year risk: 5%
Eye examination: No diabetic retinopathy
Foot examination: Normal sensation
Physical examination: Frequent dry cough; otherwise unremarkable

Hypertension Assessment and Management

Blood Pressure Evaluation

George’s blood pressure remains elevated at 142/90 mmHg despite receiving the maximum recommended dose of lisinopril. According to current hypertension guidelines, this qualifies as Stage 2 hypertension. His diabetes further increases his cardiovascular risk, making tighter blood pressure control essential.

A persistent dry cough developed after increasing lisinopril to 40 mg daily. Because ACE inhibitors commonly cause chronic dry cough through bradykinin accumulation, this adverse effect strongly suggests medication intolerance.

Recommended Medication Change

The most appropriate intervention is discontinuing lisinopril and initiating:

Losartan 50 mg orally once daily

Losartan belongs to the angiotensin II receptor blocker (ARB) class. Unlike ACE inhibitors, ARBs do not increase bradykinin levels and therefore rarely cause chronic cough.

Why Losartan Is Appropriate

Maintains kidney protection in patients with diabetes
Controls blood pressure effectively
Eliminates ACE inhibitor-induced cough
Improves medication adherence by reducing adverse effects

Common Side Effects

Dizziness
Fatigue
Upper respiratory symptoms
Nasal congestion

Serious Precautions

Hyperkalemia
Renal impairment
Symptomatic hypotension
Contraindicated during pregnancy because of fetal toxicity

Hypertension Monitoring Plan

Follow-up should include:

Blood pressure reassessment within 2–4 weeks
Serum creatinine and potassium after initiating losartan
Repeat office visit in approximately three months
Home blood pressure monitoring twice daily

Dietary Recommendations for Blood Pressure Control

Because George spends much of his time on the road, recommendations should be realistic and sustainable.

Adopt the DASH Diet

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

Fruits
Vegetables
Whole grains
Lean proteins
Low-fat dairy

This dietary pattern consistently lowers systolic blood pressure.

Reduce Sodium Intake

Choosing grilled meals instead of fried fast food and avoiding processed snacks can substantially decrease sodium intake.

Improve Fast-Food Choices

Healthier options include:

Grilled chicken
Salads with light dressing
Fresh fruit
Water instead of sugary beverages

Reduce Alcohol Intake

Reducing beer consumption from two drinks to one per day can improve blood pressure control and overall cardiovascular health.

Consider Garlic Supplementation

Evidence suggests garlic supplementation may modestly lower LDL cholesterol and blood pressure. Patients should consult their healthcare provider before beginning supplementation due to possible medication interactions.

Type 2 Diabetes Assessment

George’s HbA1c remains elevated at 7.5%, indicating suboptimal glycemic control despite maximum-dose metformin.

Contributing factors include:

Sedentary lifestyle
Frequent fast-food consumption
Excess body weight
Strong family history of diabetes

Although kidney function remains normal, improved glucose control is needed to reduce future microvascular and cardiovascular complications.

Diabetes Medication Optimization

Continue:

Metformin XR 2,000 mg daily

Add:

Liraglutide (GLP-1 receptor agonist)

GLP-1 receptor agonists improve glycemic control by:

Stimulating glucose-dependent insulin secretion
Suppressing glucagon release
Slowing gastric emptying
Promoting weight loss
Reducing cardiovascular risk in appropriate patients

Common Side Effects

Nausea
Vomiting
Diarrhea

These symptoms often improve with continued treatment.

Important Warnings

GLP-1 receptor agonists carry a boxed warning regarding the potential risk of thyroid C-cell tumors observed in animal studies and should be avoided in patients with a personal or family history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia syndrome type 2 (MEN2).

Diabetes Follow-Up Plan

Reassess in approximately three months with:

HbA1c
Weight
Renal function
Liver function tests
Lipid profile

Patients should also monitor home blood glucose regularly and maintain a log for review.

Lifestyle Strategies to Improve Glycemic Control

Recommended interventions include:

Walking during mandatory driving breaks
Replacing refined carbohydrates with whole grains
Limiting alcohol consumption
Choosing unsweetened or black coffee
Recording blood glucose and blood pressure daily

These modifications improve insulin sensitivity and support long-term diabetes management.

Hyperlipidemia Assessment

George’s lipid profile demonstrates poorly controlled dyslipidemia.

Current values include:

LDL cholesterol: 180 mg/dL
HDL cholesterol: 32 mg/dL
Triglycerides: 190 mg/dL

Because he has diabetes and markedly elevated LDL cholesterol, guideline-directed therapy supports initiating a high-intensity statin regardless of his relatively modest calculated ASCVD risk.

Hydrophilic vs. Lipophilic Statins

Hydrophilic statins primarily target hepatic tissue, whereas lipophilic statins distribute more widely throughout the body.

Examples include:

Hydrophilic

Rosuvastatin
Pravastatin

Lipophilic

Atorvastatin
Simvastatin

Understanding these pharmacologic differences helps clinicians individualize therapy, particularly for patients reporting statin intolerance.

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, thereby reducing hepatic cholesterol synthesis.

Common Side Effects

Muscle aches
Gastrointestinal discomfort
Mild elevation of liver enzymes

Serious Adverse Effects

Although uncommon, patients should immediately report:

Severe muscle pain
Dark-colored urine
Profound weakness

These symptoms may indicate rhabdomyolysis, a rare but potentially life-threatening complication.

Lipid Monitoring

Follow-up should include:

Repeat lipid panel in 4–12 weeks after initiation
Liver function testing if clinically indicated
Routine reassessment every 3–12 months depending on treatment response

Key Clinical Takeaways

George’s case demonstrates the importance of individualized chronic disease management.

Optimal treatment includes:

Switching lisinopril to losartan because of persistent ACE inhibitor-induced cough
Continuing metformin while adding a GLP-1 receptor agonist
Starting high-intensity atorvastatin therapy
Implementing realistic dietary and lifestyle changes compatible with long-haul trucking
Regular laboratory monitoring and home blood pressure and glucose tracking

Early intervention and consistent follow-up reduce cardiovascular risk and improve long-term outcomes.

Patients with diabetes who develop a persistent dry cough while taking lisinopril should be evaluated for ACE inhibitor-induced cough.

Replacing lisinopril with an angiotensin receptor blocker such as losartan often resolves symptoms while maintaining blood pressure control and renal protection.

Patients with Type 2 diabetes who remain above HbA1c target despite maximum-dose metformin may benefit from adding a GLP-1 receptor agonist.

GLP-1 receptor agonists improve glycemic control, promote weight loss, and provide cardiovascular benefits in appropriate patients.

Adults with diabetes and markedly elevated LDL cholesterol should generally receive high-intensity statin therapy.

High-intensity statins substantially reduce LDL cholesterol and lower the risk of future cardiovascular events.

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 the symptom.

Why is losartan preferred over continuing lisinopril?

Losartan provides similar blood pressure control and kidney protection without the cough associated with ACE inhibitors.

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

Metformin remains first-line therapy. Adding a GLP-1 receptor agonist improves glucose control, supports weight loss, and lowers cardiovascular risk without discontinuing metformin.

Why should George begin statin therapy now?

His LDL cholesterol is significantly elevated, and diabetes increases cardiovascular risk. Current evidence supports initiating high-intensity statin therapy to reduce future cardiovascular events.

What lifestyle changes would have the greatest impact?

The most effective changes include improving food choices while traveling, increasing daily walking, reducing sodium intake, limiting alcohol, monitoring blood glucose, and maintaining consistent medication adherence.

References

American Diabetes Association. (2025). Standards of care in diabetes—2025. Diabetes Care.

Basile, J., & Bloch, M. (2021). Overview of hypertension in adults. UpToDate.

Centers for Disease Control and Prevention. (2024). High cholesterol: Risk factors.

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.

Mayo Clinic. (2024). Statin side effects: Weigh the benefits and risks.

National Center for Complementary and Integrative Health. (2024). Garlic.