1. Hypertension Presentation: Most are not symptomatic, Occipital Headaches, headache on awakening in am, burry vision . Look for these clinical findings 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 Macrovascu lar 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 o ptic fundi: Look for AV nicking , hemorrhage, papilledema LVH (long standing HTN) Perform exam of symmetrical pulses Auscultate for Carotid bruits , abdominal bruits , and k idney 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 leg s), 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 s odium 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 Pharmacolo gic 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%): Atorva statin 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, microalbuminur ia 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
