Foundations in Herbal Medicine: Cardiology Case Study
HPI: Mark is a 62-year old man who comes in to see you for help with his hypertension and
elevated cholesterol. He took simvastatin but discontinued it when he felt his muscles “locking up
and seizing.” He then tried rosuvastatin but had similar effects. His cardiologist wants to try him
on another statin but Mark refuses. His blood pressure is elevated, he takes a “diuretic” but that
makes him urinate more at night, which further aggravates his insomnia. He has cut back on salt
and wants to go off his medication. He has varicose veins in both legs, which he says bother him
when he stands for long periods at work. Mark says that once he hit 60 “things just started falling
apart.” He had a normal stress test in 2013. He has a strong family history of coronary artery
disease.
He complains of significant insomnia. His sleep has gotten worse over the past year, he isn’t sure
why. He states that nothing has “changed” in his life. He still teaches high school everyday and
enjoys his students, though he feels he is less patient and more easily annoyed. He sleeps
approximately 3-5 hours per night with frequent awakenings. Lately, he has been having several
scary nightmares. They usually involve “someone menacing in the shadows, I can never see his
face but I know he wants to kill me. I wake up in a panic.” He denies any PTSD, any severe
trauma or history of violence. He doesn’t believe he needs to see anyone about it, “just thought
I’d mention it, doc.”
He had a sleep study that showed he did not have sleep apnea and was given sleep hygiene
recommendations. He says that he tries to follow most of them, though he does drink 2-3 glasses
of wine at night and is “not going to give that up. I love good wine.” But Mark does not feel
refreshed when he awakes and struggles with daytime fatigue. He drinks 4-5 cups of coffee per
day, including late in the afternoon, to stay alert at work. His mind races when he lies down to go
to sleep. His wife feels frustrated by his constant tossing and turning and wants him to sleep in
guest bedroom, which may be in part due to their lack of romance.
John finds that his libido is very low and though he loves his wife and is attracted to her, he has
no sexual desire. They have intercourse every 3-4 months but he is has difficulty maintaining his
erection. He was given a prescription for Viagra, which he used once but it gave him a headache.
It did help, however. His wife wants him to take it more often but he is reluctant as he thought the
headache was pretty severe.
He feels frustrated and wants to try a more integrative approach to get his health back on track.
Review of Systems:
General: Negative for fever, fatigue, poor appetite or recent weight change
Vision: wears glasses for reading (last eye exam 2 years ago)
Hearing: normal
CV: Denies chest, arm or jaw discomfort, fainting, swelling in feet or legs, shortness of breath at
rest, with walking or while sleeping, palpitations or irregular heart beat. Fatigue in his legs after
standing for long periods.
Respiratory: denies problems with snoring, sleep apnea, wheezing, or cough
Bowel: Complains of some gas and bloating, particularly when eating fatty foods. Has some
constipation, somewhat dry stools every 2-3 days. Denies nausea, vomiting, history of stomach
ulcer, heartburn, black or bloody stool.
Genitourinary: Denies burning sensation on urination, difficulty starting urine stream or trouble
emptying bladder; has some difficulty maintaining erection as mentioned in HPI
Musculoskeletal: Denies joint or back pain, denies restless legs
Skin: denies any skin disorders, or new rashes or lesions
Neurological: Denies lightheadedness, unsteady gait, frequent or severe headaches (except with
Viagra as mentioned in HPI), dizziness, or seizures.
Mental Health: Admits he sometimes feels mildly depressed, which he describes as sad and
overwhelmed. Only lasts a couple days and then “he pulls himself out of it.” Denies suicide
ideation. He is having nightmares (~ four in last 3 months) and feels more tense and less patient
at work.
Endocrine: Denies excessive intolerance to cold or heat or excessive thirst or frequent urination
Bleeding: denies history of blood clots in legs or lungs, or excessive bruising or bleeding
Cardiac risk factors:
- hypertension, - diabetes mellitus, -tobacco use. He has a strong family history of CAD.
+ hyperlipidemia
+waist circumference 39 inches
Allergies:
No known allergies
Medications: aspirin 325 mg every day, diphenhydramine (Benadryl) 50 mg at night for sleep
Family History: Father died at age 64 from heart attack, mother passed away age 69 after
stroke. He has 1 sister that is alive.
Sister, age 58, has diabetes and coronary artery disease.
Social History: Married for 32 years. He has one daughter, age 29 who is married and lives in
Chicago. He enjoys his wife’s company. She works as a second grade teacher. He has been a high
school math teacher since he graduated college. He enjoys his work, though, he finds the days are
long and the kids more unruly.
Past Medical History:
1. Hyperlipidemia
2. Hypertension
3. Insomnia
Past Surgical History:
1. Tonsillectomy (age 5 for recurrent sore throats)
Smoking history: He does not smoke cigarettes. He smoked pack/day from ages 18-46.
Caffeine intake: he drinks 4-5 cups of coffee
Alcohol intake: 2-3 servings wine 7 nights per week
Exercise: does not do any exercise
Spirituality: Raised Lutheran. Has no active practice. “Not interested. We’re here, we live, we
die. The end.”
Relaxation: watches football and other television shows, usually with his wife.
Supplements: does not take any supplements
Stress level: Rates himself 8 on a scale of 1-10 (10 being considerable stress)
Mental health: Rates himself 7 on a scale of 1 to 10 (10 being depressed)
Sleep habits: Goes to bed around 9 PM and watches TV until around 11. Falls asleep for 1-2
hours. Wakes up and can’t go back to sleep until around 4 AM. Then falls asleep until around 6
AM when he gets up to get ready to go to work. Takes Benadryl to help with sleep. Has never
taken prescription sleep aids.
Nutrition
He eats 2-3 servings of vegetables in an average day.
He eats 0-1 servings of fruit in an average day.
He eats fried or "fast" food 5/week times a week.
He eats red or processed meat 4-5 times a week.
Height: 6 feet 2 inches, weight 255 pounds, BMI 32.81 BP 142/84, HR 68 bpm
Appearance: Well dressed man in no apparent distress, looks his age. Speech is clear and
appropriate. Affect is somewhat flat. Gait is steady and coordinated.
HEENT:
Pupils equal, react to light and accommodation.
Neck:
No JVD appreciated. No carotid bruits bilaterally, no thyromegaly
Cardiac:
S1S2, regular rate and rhythm, no S3 or S4 appreciated.
Pulmonary:
Bilaterally clear without wheezes, rales or rhonchi
Abdomen:
soft, nontender, no masses appreciated, no heptasplenomegaly, bowel sounds
present
Extremities:
No edema, pulses present; 2+ dorsalis pedis and 2+ posterior tibial pulses,
varicose veins very pronounced in lower legs bilaterally
Skin:
No rashes, lesions
Neuro:
Non- focal, cranial nerves 2-12 intact
Labs:
LDL:
HDL:
Triglycerides:
hs-CRP:
176 mg/dL
44 mg/dL
266 mg/dL
3.1
CHEM20:
normal
Thyroid panel: normal
Vitamin D:
19 ng/ml