NR 661 Week 4 Vise Assignment Study Guide Common Diagnosis: Summer 2021/2022

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1. Hypertension Presentation: Most are not symptomatic, Occipital Headaches, headache on awakening in am, blurry vision, Assessment:  Asymptomatic  Occipital headache  Blurry vision �... � Headache upon wakening  Look for AV nicking  LVH Exam:  Carotid bruits  Abdominal bruits  Kidney bruits Diagnostic studies: to look for secondary causes of HTN like target organ damage and establish ASCVD risk: EKG, fasting lipid profile, fasting blood glucose, CBC, CMP (electrolyte, creatinine, & calcium levels), and urinalysis (checking for proteinuria). Diagnosis: Measure BP 5 minutes apart. Average of 2 or more BP readings on two different visits at > 140/90 mm Hg start then can be diagnosed with HTN. If Stage 1 (ASCVD <10%) then non-pharmacologic management only:  First: Lifestyle modifications: diet and exercise 30 minutes aerobic exercise 5 days per week.  Limit alcohol  stop smoking  stress management.  DASH  Medication compliance  Reduce sodium intake  Measure BP daily If Stage 2 (ASCVD >10% and known CAD) initiate lifestyle + Pharmacologic Management:  Alone: hydrochlorothiazide (HCTZ) 25 mg/day (chlorthalidone is preferred over HCTZ)  Alone: lisinopril 10mg/day complicated HTN first line  Combo: thiazide + ACE or ARB  Alternative CB (especially in isolated HTN seen mainly in older adults)  Black population: thiazide + CCB is recommended first line Follow up:  2-4weeks Referral:  Cardiology if EKG is abnormal Differential:  Secondary hypertension  Pregnant  Pregnancy induced hypertension Hollier: page 62 2 2. Hyperlipidemia Etiology: may be familial, dietary, obesity, hypothyroid, renal disorders, thiazide or beta blocker use, alcohol and/or caffeine intake Presentation: few physical findings  Xanthomata (lipid deposits around the eyes)  Corneal Arcus prior to age 50 years (white iris), normal  Angina  Bruits  MI  Stroke Diagnostics:  Fasting/nonfasting lipid profile (total cholesterol, LDL, and HDL minimally affected by eating)  Glucose,  UA and creatinine (for detection of nephrotic syndrome which can induce dyslipidemia),  TSH (for detection of hypothyroidism) Diagnosis: Pt with LDL >= 190mg/dL Non-pharmacologic Management:  Lifestyle Modification; diet and exercise. Pharmacologic Management Those who benefit most from statin therapy include:  hx of CVD or stroke,  LDL 190 or greater,  DM with LDL 70-189,  no evidence of ASCVD or DM but have LDL 70-189 PLUS an estimated ASCVD risk of 7% or greater  High risk: o Atorvastatin 40 or 80 mg daily o Rosuvastatin 20 or 40 mg daily  Moderate risk: o Atorvastatin 10 or 20 mg daily o (other statin medications also listed in Hollier)  If statins not tolerated, temporarily stop, decrease dose, and re-challenge with 2-3 statins of differing metabolic pathways and intensities. Follow up:  after initiating therapy, follow-up every 6-8 weeks until goal attained then every 6-12 months to evaluate compliance  evaluate lipids every 5 years starting at age 20 if normal values obtained Refer: Nutritionist Differentials: consider secondary causes  Hypothyroidism  Pregnancy  Diabetes  Non-fasting state Hollier: page 55 3 3. Diabetes type 2 - Etiology: genetics, high BMI with central obesity, inactivity, drug or chemical induced like glucocorticoids or antiretroviral therapy Risk factors:  BMI >/= 25  Hx of gestational diabetes  First or second degree relative with DM  PCOS, acanthosis nigricans  HDL-C <35 / TG >250  HTN or HTN treatment meds  CVD Presentation (assessment): insulin resistance in target tissues  Polydipsia, Polyuria, Polyphagia, (showing symptoms)  agitation,  nervousness,  obesity,  fatigue  blurry vision  Exam feet, pulses, nail thickness, odor, swelling, mobility Diagnostics: EKG, CBC and urinalysis (glucosuria, proteinuria, hyperglycemia), CMP, LIPIDS< Microalbuminuria, TSH, A1C Diagnosis:  Diabetes  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/prevention:  Weight loss (5-10 pound goal)  Monitor Blood glucose at home and diary (daily)  Exercise 150 minutes or more per week (no more than 2 consecutive days without activity); resistance training 2-3 days per week on nonconsecutive days  avoid alcohol  avoid smoking Pharmacologic Management:  First: Initiate metformin 500mg BID if not contraindicated, then, when needed add-  Actos 15 mg daily, then, when needed add-  Levemir 10 units once a day  *Initiate insulin early in course of oral therapy: 0.1-0.2 units/kg/day or 10 units daily of peakless insulin  With older adults, start low and go slow Follow up:  recheck A1C in 90 days  Screening in adults >45 years be done every 3 years and ore often if fasting glucose close to 126 4  Screen patients with hx of gestational diabetes at 6-12 weeks gestation with OGTT and Q3years after that for life Referral:  Ophthalmologist at time of diagnosis  Fundoscopic exam  Diabetic educator/ specialist  Podiatry Education:  Carbs 50%  Protein 30%  Fat 20%  Good glycemic control – no low sugars  10-15 years develop complications Complications (usually present within 10-15 years after onset of DM but may earlier):  Neuropathy  Nephropathy  Glaucoma = blindness  Cataracts  Charcot foot Differentials:  Gestational diabetes  Cushing’s syndrome  Corticosteroid use Hollier: page 216 4. Back pain – Etiology: often unable to pinpoint; may be due to stretching or tearing of nerves (radiculopathy), muscles, tendons, ligaments, or fascia of the back secondary to trauma or just chronic mechanical stress; compression or irritation of the nerve roots are common Presentation:  back pain complaint, buttock or one or more thighs that is aggravated by movement, rising from seated positions, standing, and flexion (may be relieved by rest)  muscle spasm may be present over lumbosacral area  Maybe localized, referred, or radiating (down leg and below knee)  Assess rectal tone in those describing cauda equina  Motor, sensory, and reflex exams should be done o DTRs: patellar tests nerve roots at L2-L4 & Achilles tests nerve roots at S1-S2 o Diminished or absent imply myopathies, decreased muscle mass, and nerve root impairment  New onset of radicular pain on older adults is often sign of spinal stenosis  Straight leg raise test: elevation of affected leg in supine will elicit pain at 20-30 degrees for severe disease, 30-60 degrees for moderate.  Determine OLDCARTS, any pre-existing conditions, past surgeries or trauma which may be contributing. Diagnostics: (see imaging below) 5  routine imaging is not recommended f [Show More]

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