NR 667 VISE Assignment
Etiology: Allergic rhinitis - CORRECT ANSWER--Any substance or condition that
causes an IgE-mediated response characterized by rupture of mast cells and release of
histamines, leukotrienes, prostaglandins, and other compounds
-Seasonal allergens: pollens from grass, trees, weeds
-Perennial allergens: mold, animal dander, dust mites, smoke
Risk factors: Allergic rhinitis - CORRECT ANSWER--Family history
-Other topics diseases (asthma, atopic dermatitis, allergic conjunctivitis, food allergy)
-Repeated exposure to the allergen
-Non-adherence to treatment
Assessment findings: Allergic rhinitis - CORRECT ANSWER--DX is based on h+p
findings consistent with allergy-related cause; presence of one or more of these
symptoms: nasal congestion, rhinorrhea, itchy nose, sneezing
-Conjunctival injection, watery eyes
-Pale, boggy nasal mucosa with congestion and clear rhinorrhea
-Transverse crease on tip of nose due to allergic salute-repeated wiping of nose in an
upward direction
-Mouth breathing, dry lips
-Sore throat, dry mouth upon waking
-Palpable lymph nodes
-Enlarged tonsils and adenoids
-Presence of associated conditions: sleep-disordered breathing, otitis media,
rhinosinusitis, conjunctivitis, asthma, atopic dermatitis
Differential diagnosis: Allergic rhinitis - CORRECT ANSWER--Vasomotor rhinitis
-Rhinitis medicamentosa
-Infection
-Tumors
-Nasal foreign body
-Common cold
-Granulomatous diseases
-CSF rhinorrhea
Final Diagnosis: Allergic rhinitis - CORRECT ANSWER--Usually none
-CBC: eosinophilia if acute reaction
-CT scan is primary imaging study
-Allergy testing for those that don't respond to empiric treatment (stop antihistamines 1
week before testing)
-RAST: specific IgE test for patients in whom severe reaction is possible
,Prevention: Allergic rhinitis - CORRECT ANSWER--Minimize continuous exposure to
commonly known allergens
-Remove offending allergens from environment
-Adherence to pham regimen
-Avoidance of allergen is first-line treatment
Prevention: Hypertension - CORRECT ANSWER--Maintaining healthy weight and BMI
-Smoking cessation
-Regular aerobic exercise
-Alcohol in moderation (< 1 oz/day)
-Stress management
-Medication compliance
-Assess for and treat OSA
Non-pharm management: Hypertension - CORRECT ANSWER--Stage 1: Risk score <
10% =lifestyle modification
-Stage 2: lifestyle + medication
-DASH eating plan: high fruit, veggies, grains; low fat dairy, fish, poultry, beans, nuts
-Reduce dietary sodium to 2,300mg/day, increase K+
-Reduce sat. fat intake
-Body weight reduction; 1kg of weight reduction = 1 mm/hg bp reduction
-150 mins of aerobic exercise and/or 3 sessions of isometric resistance per week
-Treat other underlying diseases
-Check bp 2x/week during pregnancy
Pharmacological management: Hypertension - CORRECT ANSWER--Start medication
for primary prevention of CVD if pt. has ASCVD risk ≥ 10% and stage 1 HTN or if
ASCVD is < 10% with bp >140/90
-Stage 2: start 2 bp-lowering medications
-African Americans: 2+ medications recommended; thiazide and CCBs are the most
effective
*DO NOT use ACE and ARB concurrently
-Beta blockers are NOT first line
-Thiazides, CCBs, ACEIs, and ARBs can be used alone or in combo
Pregnancy considerations: Hypertension - CORRECT ANSWER--Can use beta
blockers (labetalol), methyldopa, CCBs (nifedipine)
-AVOID ARBs and ACEIs
Follow-up: Hypertension - CORRECT ANSWER--Inquire about adherence and any side
effects
-Reassess monthly until patient reaches goal, then every 3-6 months as needed
Expected course: Hypertension - CORRECT ANSWER--Only 54% of treated patients
are at goal treatment; expect complications if under treated
-Most patients require more than one medication to reach goal bp
,Possible Complications: Hypertension - CORRECT ANSWER--Stroke, CAD, MI, renal
failure, heart failure, eclampsia (seizures), pulmonary edema, hypertensive crisis,
hypertensive retinopathy, ED
Etiology: Hyperlipidemia - CORRECT ANSWER--Inherited disorder, high dietary intake,
obesity, sedentary lifestyle, DM, hypothyroidism, anabolic steroid use, hepatitis,
cirrhosis, uremia, nephrotic syndrome, stress, drug-induced (thiazide diuretics, beta
blockers, cyclosporine), alcohol, caffeine, metabolic syndrome
Risk factors: Hyperlipidemia - CORRECT ANSWER--Family history, physical inactivity,
smoking, age (men > 45, women > 55 or premature menopause without estrogen
replacement), obesity, diet high in sat. fat, DM
Assessment findings: Hyperlipidemia - CORRECT ANSWER--Few physical findings;
xanthomata (fat deposits in the skin), xanthelasma (yellow plaques on the eyelid),
corneal arcus prior to age 50 (arc of cholesterol around the iris), bruits, angina pectoris,
MI, stroke
Differential diagnosis: Hyperlipidemia - CORRECT ANSWER--Secondary causes:
hypothyroidism, pregnancy, DM, non-fasting state
Final diagnosis: Hyperlipidemia - CORRECT ANSWER--Fasting lipid profile: 9-12 hours
-Glucose level
-Urinalysis, creatinine (for detection of nephrotic syndrome which can induce
dyslipidemia)
-Baseline transaminases
-TSH for detection of hypothyroidism (which can cause secondary dyslipidemia)
-Calculate ASCVD 10-year risk
Prevention: Hyperlipidemia - CORRECT ANSWER--Healthy lifestyle reduces ASCVD in
all age groups
-Dietary interventions: encourage mediterranean and DASH diet; limit saturated and
trans fats; limit sodium intake; increase fiber, vegetables, fruits, and other whole grains;
eat lean meats (poultry, fish); eggs, beans, nuts, low-fat dairy, avoid red meat, limit
sugary drinks and sweets
-Mod to vigorous exercise of at least 40 mins 3-4x/week (sustained aerobic activity
increases HDL, decreases total cholesterol)
-Avoid tobacco
-Appropriately manage systemic diseases (DM, hypothyroidism, HTN)
Non-pharm management: Hyperlipidemia - CORRECT ANSWER--Nutrition, weight
reduction, increased physical activity, patient education about risk factors
Pharmacological management: Hyperlipidemia - CORRECT ANSWER--Assign to a
statin treatment group using ASCVD 10-year risk calculator
, -Primary lipid target it LDL
-Statins are 1st-line therapy
-Combo of statin and non-statin in some patients
-Consider adding non-statin if unable to achieve LDL < 70mg/dl, but VERIFY adherence
to statins and lifestyle changes
-Non-statins: ezetimibe (1st), bile acid sequestrant, vibrate, PCSK9 inhibitor
Pregnancy/lactation consideration: Hyperlipidemia - CORRECT ANSWER--Cholesterol
is usually elevated during pregnancy; measurement is not recommended and treatment
is contraindicated
Follow-up: Hyperlipidemia - CORRECT ANSWER--Check fasting lipid panel 4-12 weeks
after starting or adjusting a statin or non-statin
-Monitor for medication compliance and lifestyle modification, especially if LDL drop is
less than expected
Expected course: Hyperlipidemia - CORRECT ANSWER--Depends on etiology and
severity of disease
-1% decrease in LDL value decreases CHD risk by 2%
Etiology: Hypertension - CORRECT ANSWER--No known cause in 90% of cases of
primary HTN
-Secondary causes: renal failure, kidney disease, renal artery stenosis, Cushing
syndrome, hyper/hypo thyroidism, increased ICP, sleep apnea, oral contraceptives,
steroids, cocaine, NSAIDs, decongestants, sympathomimetics, alcohol,
antidepressants, caffeine
Risk Factors: Hypertension - CORRECT ANSWER--Modifiable: smoking, DM, high
cholesterol, obesity (single most important factor in children), physical inactivity, poor
diet, excessive sodium intake, excessive alcohol consumption
-Non-modifiable: CKD, family hx, increased age (>55 men, > 65 women), low
socioeconomic status, low educational status, male sex, OSA, stress, pregnancy
Assessment: Hypertension - CORRECT ANSWER--Most are asymptomatic; occipital
headache, headache upon waking, blurry vision, fundoscopic exam (AV nicking,
exudates, papilledema), left vent. hypertrophy, pregnancy w/HTN and proteinuria,
edema, and excessive weight gain
Differential Diagnosis: Hypertension - CORRECT ANSWER--Secondary HTN, white
coat HTN (artificial elevation d/t medical environment anxiety)
Final Diagnosis: Hypertension - CORRECT ANSWER--Urinalysis = proteinuria
-Electrolytes, creatinine, calcium
-Fasting lipid profile and BS
-ECG
Etiology: Allergic rhinitis - CORRECT ANSWER--Any substance or condition that
causes an IgE-mediated response characterized by rupture of mast cells and release of
histamines, leukotrienes, prostaglandins, and other compounds
-Seasonal allergens: pollens from grass, trees, weeds
-Perennial allergens: mold, animal dander, dust mites, smoke
Risk factors: Allergic rhinitis - CORRECT ANSWER--Family history
-Other topics diseases (asthma, atopic dermatitis, allergic conjunctivitis, food allergy)
-Repeated exposure to the allergen
-Non-adherence to treatment
Assessment findings: Allergic rhinitis - CORRECT ANSWER--DX is based on h+p
findings consistent with allergy-related cause; presence of one or more of these
symptoms: nasal congestion, rhinorrhea, itchy nose, sneezing
-Conjunctival injection, watery eyes
-Pale, boggy nasal mucosa with congestion and clear rhinorrhea
-Transverse crease on tip of nose due to allergic salute-repeated wiping of nose in an
upward direction
-Mouth breathing, dry lips
-Sore throat, dry mouth upon waking
-Palpable lymph nodes
-Enlarged tonsils and adenoids
-Presence of associated conditions: sleep-disordered breathing, otitis media,
rhinosinusitis, conjunctivitis, asthma, atopic dermatitis
Differential diagnosis: Allergic rhinitis - CORRECT ANSWER--Vasomotor rhinitis
-Rhinitis medicamentosa
-Infection
-Tumors
-Nasal foreign body
-Common cold
-Granulomatous diseases
-CSF rhinorrhea
Final Diagnosis: Allergic rhinitis - CORRECT ANSWER--Usually none
-CBC: eosinophilia if acute reaction
-CT scan is primary imaging study
-Allergy testing for those that don't respond to empiric treatment (stop antihistamines 1
week before testing)
-RAST: specific IgE test for patients in whom severe reaction is possible
,Prevention: Allergic rhinitis - CORRECT ANSWER--Minimize continuous exposure to
commonly known allergens
-Remove offending allergens from environment
-Adherence to pham regimen
-Avoidance of allergen is first-line treatment
Prevention: Hypertension - CORRECT ANSWER--Maintaining healthy weight and BMI
-Smoking cessation
-Regular aerobic exercise
-Alcohol in moderation (< 1 oz/day)
-Stress management
-Medication compliance
-Assess for and treat OSA
Non-pharm management: Hypertension - CORRECT ANSWER--Stage 1: Risk score <
10% =lifestyle modification
-Stage 2: lifestyle + medication
-DASH eating plan: high fruit, veggies, grains; low fat dairy, fish, poultry, beans, nuts
-Reduce dietary sodium to 2,300mg/day, increase K+
-Reduce sat. fat intake
-Body weight reduction; 1kg of weight reduction = 1 mm/hg bp reduction
-150 mins of aerobic exercise and/or 3 sessions of isometric resistance per week
-Treat other underlying diseases
-Check bp 2x/week during pregnancy
Pharmacological management: Hypertension - CORRECT ANSWER--Start medication
for primary prevention of CVD if pt. has ASCVD risk ≥ 10% and stage 1 HTN or if
ASCVD is < 10% with bp >140/90
-Stage 2: start 2 bp-lowering medications
-African Americans: 2+ medications recommended; thiazide and CCBs are the most
effective
*DO NOT use ACE and ARB concurrently
-Beta blockers are NOT first line
-Thiazides, CCBs, ACEIs, and ARBs can be used alone or in combo
Pregnancy considerations: Hypertension - CORRECT ANSWER--Can use beta
blockers (labetalol), methyldopa, CCBs (nifedipine)
-AVOID ARBs and ACEIs
Follow-up: Hypertension - CORRECT ANSWER--Inquire about adherence and any side
effects
-Reassess monthly until patient reaches goal, then every 3-6 months as needed
Expected course: Hypertension - CORRECT ANSWER--Only 54% of treated patients
are at goal treatment; expect complications if under treated
-Most patients require more than one medication to reach goal bp
,Possible Complications: Hypertension - CORRECT ANSWER--Stroke, CAD, MI, renal
failure, heart failure, eclampsia (seizures), pulmonary edema, hypertensive crisis,
hypertensive retinopathy, ED
Etiology: Hyperlipidemia - CORRECT ANSWER--Inherited disorder, high dietary intake,
obesity, sedentary lifestyle, DM, hypothyroidism, anabolic steroid use, hepatitis,
cirrhosis, uremia, nephrotic syndrome, stress, drug-induced (thiazide diuretics, beta
blockers, cyclosporine), alcohol, caffeine, metabolic syndrome
Risk factors: Hyperlipidemia - CORRECT ANSWER--Family history, physical inactivity,
smoking, age (men > 45, women > 55 or premature menopause without estrogen
replacement), obesity, diet high in sat. fat, DM
Assessment findings: Hyperlipidemia - CORRECT ANSWER--Few physical findings;
xanthomata (fat deposits in the skin), xanthelasma (yellow plaques on the eyelid),
corneal arcus prior to age 50 (arc of cholesterol around the iris), bruits, angina pectoris,
MI, stroke
Differential diagnosis: Hyperlipidemia - CORRECT ANSWER--Secondary causes:
hypothyroidism, pregnancy, DM, non-fasting state
Final diagnosis: Hyperlipidemia - CORRECT ANSWER--Fasting lipid profile: 9-12 hours
-Glucose level
-Urinalysis, creatinine (for detection of nephrotic syndrome which can induce
dyslipidemia)
-Baseline transaminases
-TSH for detection of hypothyroidism (which can cause secondary dyslipidemia)
-Calculate ASCVD 10-year risk
Prevention: Hyperlipidemia - CORRECT ANSWER--Healthy lifestyle reduces ASCVD in
all age groups
-Dietary interventions: encourage mediterranean and DASH diet; limit saturated and
trans fats; limit sodium intake; increase fiber, vegetables, fruits, and other whole grains;
eat lean meats (poultry, fish); eggs, beans, nuts, low-fat dairy, avoid red meat, limit
sugary drinks and sweets
-Mod to vigorous exercise of at least 40 mins 3-4x/week (sustained aerobic activity
increases HDL, decreases total cholesterol)
-Avoid tobacco
-Appropriately manage systemic diseases (DM, hypothyroidism, HTN)
Non-pharm management: Hyperlipidemia - CORRECT ANSWER--Nutrition, weight
reduction, increased physical activity, patient education about risk factors
Pharmacological management: Hyperlipidemia - CORRECT ANSWER--Assign to a
statin treatment group using ASCVD 10-year risk calculator
, -Primary lipid target it LDL
-Statins are 1st-line therapy
-Combo of statin and non-statin in some patients
-Consider adding non-statin if unable to achieve LDL < 70mg/dl, but VERIFY adherence
to statins and lifestyle changes
-Non-statins: ezetimibe (1st), bile acid sequestrant, vibrate, PCSK9 inhibitor
Pregnancy/lactation consideration: Hyperlipidemia - CORRECT ANSWER--Cholesterol
is usually elevated during pregnancy; measurement is not recommended and treatment
is contraindicated
Follow-up: Hyperlipidemia - CORRECT ANSWER--Check fasting lipid panel 4-12 weeks
after starting or adjusting a statin or non-statin
-Monitor for medication compliance and lifestyle modification, especially if LDL drop is
less than expected
Expected course: Hyperlipidemia - CORRECT ANSWER--Depends on etiology and
severity of disease
-1% decrease in LDL value decreases CHD risk by 2%
Etiology: Hypertension - CORRECT ANSWER--No known cause in 90% of cases of
primary HTN
-Secondary causes: renal failure, kidney disease, renal artery stenosis, Cushing
syndrome, hyper/hypo thyroidism, increased ICP, sleep apnea, oral contraceptives,
steroids, cocaine, NSAIDs, decongestants, sympathomimetics, alcohol,
antidepressants, caffeine
Risk Factors: Hypertension - CORRECT ANSWER--Modifiable: smoking, DM, high
cholesterol, obesity (single most important factor in children), physical inactivity, poor
diet, excessive sodium intake, excessive alcohol consumption
-Non-modifiable: CKD, family hx, increased age (>55 men, > 65 women), low
socioeconomic status, low educational status, male sex, OSA, stress, pregnancy
Assessment: Hypertension - CORRECT ANSWER--Most are asymptomatic; occipital
headache, headache upon waking, blurry vision, fundoscopic exam (AV nicking,
exudates, papilledema), left vent. hypertrophy, pregnancy w/HTN and proteinuria,
edema, and excessive weight gain
Differential Diagnosis: Hypertension - CORRECT ANSWER--Secondary HTN, white
coat HTN (artificial elevation d/t medical environment anxiety)
Final Diagnosis: Hypertension - CORRECT ANSWER--Urinalysis = proteinuria
-Electrolytes, creatinine, calcium
-Fasting lipid profile and BS
-ECG
