NR 667 VISE STUDY GUIDE Comprehensive Latest Update 2023 Brand New Questions Included.

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 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