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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  Abdomina...

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  • 29 mars 2022
  • 31
  • 2021/2022
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1

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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