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)
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