VISE assignment study guide

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 :