1. Hypertension
Presentation: Most are not symptomatic, Occipital Headaches, headache on awakening in am, burry vision.
Look for these clinical findings
... [Show More] to rule out organ damage:
Microvascular
• Eyes (HTN retinopathy): AV nicking (causes when arteriole crosses on top of vein), papilledema
• Kidneys: microalbuminuria and proteinuria, elevated serum creatinine and abnormal eGFR, peripheral or generalized edema
Macrovascular
• Heart: S3 (CHF), S4 (LVH), carotid bruits, decreased or absent peripheral pulses
• Brain: TIA or hemorrhagic stroke
Assessment/Exam:
• Asymptomatic
• Occipital headache
• Blurry vision
• Headache upon wakening
• Exam of optic fundi: Look for AV nicking, hemorrhage, papilledema
• LVH (long standing HTN)
• Perform exam of symmetrical pulses
• Auscultate for Carotid bruits, abdominal bruits, and kidney bruits
Diagnostic studies: EKG, fasting lipid profile, fasting blood glucose, TSH, CXR to R/O
cardiomegaly. CBC, CMP, and urinalysis. Measure BP 5 minutes apart. Assess the patients 10- year risk for heart disease (ASCVD)
Diagnosis: > 140/90 mm Hg start on B/P medication.
Pharmacologic Management:
• FIRST LINE DIURETIC: Hydrochlorothiazide (HCTZ) 25 mg/day (max 50mg/day) *May worsen gout and elevate lipids and glucose
• ALTERNATIVE CCB: Amlodipine besylate 5 mg /day. (Watch for lower extremity edema)
• ACE: lisinopril 10mg/day complicated HTN first line
• Consider ACE/ARB in patient with DM, proteinuria, HF. CONTRAINDICATED IN PREGNANCY
• If stage 2, initiate 2 drug classes (Diuretic & CCB most effective in African American)
Follow up:
• 2-4weeks
Referral:
• Cardiology if EKG is abnormal
Secondary HTN causes to consider:
• CKD, renal artery stenosis, hyperthyroidism, phenochromocytoma, OSA, coartication of the heart (SBP higher in the legs), oral contraceptives, corticosteroids, cocaine, NSAID, decongestants
Differential:
• Secondary hypertension
• White coat syndrome
• Pregnant
• Pregnancy induced hypertension
Education:
• First: Lifestyle modifications: diet and exercise 30 minutes aerobic exercise 5 days per week.
• Weight loss (BMI 25 and up)
• Limit alcohol (men:2 drinks or less per day; women: one drink or less per day)
• Stop smoking
• Stress management
• Eat fatty cold water fish (salmon, anchovy) 3x a week
• DASH
• Medication compliance
• Reduce sodium intake <1,500 mg/day)
• Measure BP daily, bring log to next visit, bring home cuff to compare to office
•
Liek: 1
Hollier: 17, 1
2. Hyperlipidemia
Presentation: Most patients are asymptomatic until they develop ASCVD.
• Xanthomata (lipid deposits around the eyes)
• Corneal Arcus prior to age 50 years (white iris), normal
• Angina
• Bruits
• MI
• Stroke
Diagnostics:
• Fasting/non-fasting lipid profile
• Glucose,
• UA and creatinine (for detection of nephrotic syndrome which can induce dyslipidemia),
• TSH (for detection of hypothyroidism)
• CMP
Diagnosis: Optimal goal is <100 mg/dL
Pt with LDL >= 190mg/dL (without ASCVD or DM is a candidate for high-intensity statin)
Non-pharmacologic Management/Education:
• FIRST LINE: Lifestyle Modification; diet and exercise.
• Diet to improve serum lipids: Mediterranean diet, DASH, vegetarian, low-carb, and low-trans fat.
• Decrease sugar and simple carbs
• Avoid alcohol
• Increase fish diet with Omega-3 (salmon and sardines) twice a week
• Weight loss
• Aerobic type exercise
Pharmacologic Management:
• First Line: Atorvastatin 10mg once a day at bedtime (perform liver function tests before initiation therapy and then 4-6 and 12 weeks and after dose increase).
a) Low Intensity (lowers LDL on average by <30%): Simvastatin 10mg, Pravastatin 10- 20mg, Lovastatin 20mg
b) Moderate Intenstiy (lowers LDL on average by 30-49%): Atorvastatin 10-20mg daily, Rosuvastatin 5-10mg, Simvastatin 20-40mg, Pravastatin 40-80mg.
c) High Intensity (lowers LDL on average by >50%): Atorvastatin 40-80mg daily. (Never start on 80mg, always titrate up). Rosuvastatin 20-40mg.
• AVOID GRAPEFRUIT JUICE! Watch for rhabdomylosis
• INTOLERANCE TO STATIN: Alternative Welchol (Bile Acid Sequestrants) 625 mg tab daily once a day.
• Age 21-75 high intensity therapy
Follow up: q6-8 weeks re-check lipids until goal is achieved, then q 6-12 months to evaluate
compliance
Risk Factors: DM, FH of HD, HTN, low HDL, age (men older than 45 and women older than 55), smoking, obesity, CAD, PVD, microalbuminuria
Refer: Nutritionist
Differentials:
• Hypothyroidism
• Pregnancy
• Diabetes
Liek: 1
Hollier: 29, 1
3. Diabetes type 2 -
Presentation (assessment): insulin resistance in target tissues, abnormal insulin secretion, or decrease in insulin receptors.
**Usually discovered on routine exam!
• Polydipsia, Polyuria, Polyphagia, (showing symptoms)
• agitation,
• nervousness,
• obesity,
• fatigue
• Chronic skin infections
• Women: chronic yeast infection
• blurry vision
• Exam feet, pulses, nail thickness, odor, swelling, mobility
• Thyroid palpitation
• Skin exam
Diagnostics: EKG, CBC, CMP, LIPIDS, Microalbuminuria, TSH, A1C
Diagnosis:
Hgb A1C >or equal to 6.5%
Fasting glucose>126mg/dl and confirmed on a different day
Fasting between 100-126 = impaired glucose Nonfasting less than 126 = normal values Recurrent yeast infections
Non-pharmacologic Management:
• Monitor Blood glucose at home and diary (daily)
• Lifestyle modification: diet and Exercise
• avoid alcohol
• avoid smoking
• Routine oral exams
Pharmacologic Management:
• First Line: Begin Metformin (Biguanide) 500mg twice a day (Max: 2000 mg a day in 2 doses).
• Additional 1st line or combo therapy: (Sulfonylureas, thiazolidinediones, GLP-1, DDP-4
• Second Line: Insulin, SGLT2, meglitinides, diphenylamine derivatives, bile sequestrants, alpha-glucosidase inhibitors
• Actos 15 mg daily
• Levemir 10 units once a day
Follow up:
• 2-4 weeks
Referral:
• Ophthalmologist at time of diagnosis and then yearly or bi-annualy if no problems
• Fundoscopic exam
• Diabetic educator/ specialist
• Nutritionist
• Podiatry
Education:
• Carbs 50%
• Protein 30%
• Fat 20%
• Good glycemic control – no low sugars
• 10-15 years develop complications
• Foot care:
a. Avoid going barefoot, test water temperature before stepping into a bath.
b. Trim toenails to shape of the toe; remove sharp edges. Do not cut cuticles.
c. Wash and check feet daily.
d. Shoes should be snug but not tight.
e. Socks should fit and be changed daily.
• Immunization: Once a year influenza vaccine. Pneumococcal vaccine, revaccination for individuals >64 years of age previously immunized.
• Increase awareness and screen for social determinant of health:
a. Financial ability to afford medications
b. Access to healthy foods
c. Community support
d. Food insecurity
Complications:
• Peripheral Neuropathy
• Nephropathy
• CKD
• Glaucoma = blindness
• Cataracts
• Delayed wound healing
• CAD/PVD
Differentials:
• Gestational diabetes
• Cushing’s syndrome
• Corticosteroid use
Liek: 1
Hollier: pg 231 - 1
4. Back pain – Low back pain is generally mechanical in nature and attributed to degenerative changes. Most commonly seen in L4-L5 and L5-S1
Classified into 3 categories:
i. Acute-less than 6 weeks
ii. Subacute-6 weeks to 3 months
iii. Chronic- symptoms for more than 3 months or on more than half the days in the prior 6 months
Presentation: back pain complaint. Maybe localized, referred, or radiating. Determine OLDCARTS, any pre-existing conditions, past surgeries or trauma which may be contributing. Diagnostics: X-ray to r/o fracture/disc degeneration (with injury only).
MRI and CT (the study of choice for evaluation of disc disease). Labs: CBC, CMP, Urinalysis, CRP
Considerations for Imaging:
• Current or recent cancer: especially breast, prostate, lung, thyroid, kidney, MM (consult patient's oncologist)
• Significant neuro deficits, progressive motor symptoms (MRI)
• History/strong suspicion for cancer (plain X-ray plus ESR)
• Symptoms of a spinal infection (MRI, CRP or both)
• Compression fracture (X-ray)
Rule out cauda equina – loss of bladder control, saddle anesthesia, incontinence – refer to ED Physical Assessment:
• Motor, sensory, and reflex exams are imperative
• Observe gait
• Assess lower extremity strength and bulk of muscles and pulses
• DTR:
i. Patellar: tests nerves at roots L2-L4
ii. Achilles: tests S1-S2
• Straight Leg Raise Test: elevation of affected leg in supine position will elicit pain at 20-30 degrees for severe disease, 30-60 degrees for moderate disease
• Cross leg raised test: elevating unaffected leg produces pain in the affected leg
Non-pharmacologic Management:
• Restrict activities that aggravate symptoms and avoid heavy lifting.
• Gradually resume activities as tolerated,
• Core strengthening workouts – abs/rectus muscles
• Apply heat for 20-30 min several times a day.
• Manage weight.
Pharmacologic Management:
• Naproxen 250-twice a day.
• Flexeril 5 mg as needed 3 times a day (no driving).
Follow up:
• Severe pain 24-48 hours
• 7-10 days moderate pain
• Every 2-4 weeks until able to resume lifestyle
Referral:
• Physical Therapy Imaging:
• If not resolved or improving in 4-6 weeks
• X-ray/ct after 4 weeks unresolved
Differentials:
• Muscle strain
• Herniated disc
• Compression fracture
• Cauda equina
• Osteoarthritis
• Spinal stenosis
Liek: 301-302
Hollier: 502, 1
5. Anxiety
Presentation: complaints of apprehension, restlessness, edginess, distractibility insomnia; Somatic complaints like fatigue, paresthesia, near syncope, dizziness, palpitation, tachycardia chest pain/tightness, dyspnea, hyperventilation, nausea vomiting diarrhea. Etc
Diagnostic: TSH, CBC, CMP, UA, Urine drug screen, Glucose, EKG (rule out cardia issues), Hamilton Anxiety scale
Diagnosis: Assess tools like
i. Hamilton Anxiety scale: Positive Greater than 18
The GAD-7 (Table 27) has been validated as a diagnostic tool and a severity assessment scale, with a score of 10 or more having good diagnostic sensitivity and specificity (Total score for the 7 items ranges from 0 to 21. Scores of 5, 10, and 15 represent cutoffs for mild, moderate, and severe anxiety)
Non-pharmacological:
• Psychotherapy/Counseling (CBT)
• healthy diet
• Avoid stressors as much as possible.
• Relaxation
• Regular exercise
• Avoid caffeine intake
• Avoid alcohol (rebound anxiety)
Pharmacological: SSRI may not achieve therapeutic response for 2-4 weeks with full response might take 12 weeks or more. ***Use of Benzodiazepines until therapeutic response reached is a short term strategy-up to 1-3 months with planned taper. (ADDICTIVE)
• Buspar 7.5mg twice a day and
• SSRI – Escitalopram (Lexapro) 10mg PO once daily. May increase in 1-2 weeks. Or Zoloft 50 mg
• Klonopin 0.25mg PO PRN twice a day for short-term use and titrate down because benzodiazepines have abuse potential. (Use in caution during the 2-4 weeks that the SSRI will take to meet partial therapeutic response) Only to be used PRN not daily
Follow up:
• 2-4 weeks
Referral:
• Psychologist/Psychiatrist
Differentials:
• Depression [Show Less]