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 Considerations for Imaging: • Current or recent cancer: especially breast, prostate, lung, thyroid, kidney, MM (consult patient's oncologist) • Significant neuro deficits, progressive motor symptoms (MRI) • History/strong suspicion for cancer (plain X-ray plus ESR) • Symptoms of a spinal infection (MRI, CRP or both) • Compression fracture (X-ray) Rule out cauda equina – loss of bladder control, saddle anesthesia, incontinence – refer to ED Physical Assessment: • Motor, sensory, and reflex exams are imperative • Observe gait • Assess lower extremity strength and bulk of muscles and pulses • DTR: i. Patellar: tests nerves at roots L2-L4 ii. Achilles: tests S1-S2 • Straight Leg Raise Test: elevation of affected leg in supine position will elicit pain at 20-30 degrees for severe disease, 30-60 degrees for moderate disease • Cross leg raised test: elevating unaffected leg produces pain in the affected leg Non-pharmacologic Management: • Restrict activities that aggravate symptoms and avoid heavy lifting. • Gradually resume activities as tolerated, • Core strengthening workouts – abs/rectus muscles • Apply heat for 20-30 min several times a day. • Manage weight. Pharmacologic Management: • Naproxen 250-twice a day. • Flexeril 5 mg as needed 3 times a day (no driving). Follow up: • Severe pain 24-48 hours • 7-10 days moderate pain • Every 2-4 weeks until able to resume lifestyle Referral: • Physical Therapy Imaging: • If not resolved or improving in 4-6 weeks X-ray/ct after 4 weeks unresolved Differentials: • Muscle strain • Herniated disc • Compression fracture • Cauda equina • Osteoarthritis • Spinal stenosis Liek: 301-302 Hollier: 502, 1 5. Anxiety Presentation: complaints of apprehension, restlessness, edginess, distractibility insomnia; Somatic complaints like fatigue, paresthesia, near syncope, dizziness, palpitation, tachycardia chest pain/tightness, dyspnea, hyperventilation, nausea vomiting diarrhea. Etc Diagnostic: TSH, CBC, CMP, UA, Urine drug screen, Glucose, EKG (rule out cardia issues), Hamilton Anxiety scale Diagnosis: Assess tools like i. Hamilton Anxiety scale: Positive Greater than 18 The GAD-7 (Table 27) has been validated as a diagnostic tool and a severity assessment scale, with a score of 10 or more having good diagnostic sensitivity and specificity (Total score for the 7 items ranges from 0 to 21. Scores of 5, 10, and 15 represent cutoffs for mild, moderate, and severe anxiety) Non-pharmacological: • Psychotherapy/Counseling (CBT) • healthy diet • Avoid stressors as much as possible. • Relaxation • Regular exercise • Avoid caffeine intake • Avoid alcohol (rebound anxiety) Pharmacological: SSRI may not achieve therapeutic response for 2-4 weeks with full response might take 12 weeks or more. ***Use of Benzodiazepines until therapeutic response reached is a short term strategy-up to 1-3 months with planned taper. (ADDICTIVE) • Buspar 7.5mg twice a day and • SSRI – Escitalopram (Lexapro) 10mg PO once daily. May increase in 1-2 weeks. Or Zoloft 50 mg • Klonopin 0.25mg PO PRN twice a day for short-term use and titrate down because benzodiazepines have abuse potential. (Use in caution during the 2-4 weeks that the SSRI will take to meet partial therapeutic response) Only to be used PRN not daily Follow up: • 2-4 weeks Referral: • Psychologist/Psychiatrist Differentials: • Depression Bipolar disorder • Personality disorder • ADD • PTSD • Substance abuse withdrawl or current intoxication • Substance abuse reaction • Anemia • Asthma • COPD • Arrhythmias Liek: Hollier: 649-650, 6. Depressive Disorder Presentation: loss of interest or pleasure, suicide Ideology, early morning wakening Hopelessness, depressed mood, fatigue, loss of energy, feelings of worthlessness, hypersomnia, weight loss Risk factors: • Female • Psychosocial stressors • Physical or chronic illnesses (PAIN) • Hx of depression • Postpartum period • Family history of depression • Alcohol substance abuse • Significant losses Diagnostic: CBC, CMP, TSH (rule out hypothyroidism), urine drug screen, ECG baseline. Vit B12, folate levels, Vit D (r/o organic deficiency) Screening tools: • Patient Health Questionnaire 9 (PHQ-9) score of 5 and above • Becks Depression Inventory Non-pharmacological: • Identify suicidal ideation and plan and safety (ER) • Hotline resources, • sleep hygiene at same time every day, routine schedule • home safety • Counseling • Avoid triggers Pharmacological: Continue treatment for 4-9 months after symptoms have resolved to prevent relapse. • SSRI: Citalopram (Celexa) 20 mg PO once daily, may increase to 40mg after 1 week. OR Escitalopram (Lexapro) 10 mg PO once daily, may increase in 1-2 weeks. **Need baseline ECG; long term use may prolong QT Follow up: 2 weeks to check for compliance and side effects. Wait 4-8 weeks before changing doses. Referral: Psychologist for psychotherapy (works best in conjunction with antidepressant than single therapy) Differentials: Bipolar • substance abuse • medication abuse • medication withdrawal • hypothyroidism • B12/Folate deficiency • Dementia Hollier 628; Leik 363 7. Obesity Presentation: Chronic disease due to abnormal/excessive fats accumulate which impairs health Increased morbidity and morality Defined as 20% more than ideal body mass index Parental obesity, hypothyroidism, cushing syndrome, diabetes, Diagnostics: TSH, Lipid panel, glucose/A1c, CBC, CMP, Lipase, EKG, associated with PCOS Diagnosis: BMI >30 Non-Pharmacological: • Lifestyle modification: exercise and diet • Dietary intake and eating habits • Modify times of eating • Less calories consistently Pharmacological: • Adipex-P 37.5mg daily x12weeks Follow up: 2-4 weeks Referral: Nutritionist/dietitian Liek:196-197,1 Hollier:319, 8. GERD: movement of GI contents into esophogaus d/t decreased LES tone. Subjective findings: Heartburn, burning beneath the sternum, postprandial and nocturnal, regurgitation, chest pain, neck pain, chronic cough. Dysphagia, sour taste in mouth, lump in throat, post nasal drip, erosion of teeth by acid Diagnosis: Based on symptoms of heartburn and regurgitation. Empiric PPI treatment should be started for 8 weeks. Diagnostic: Endoscopy after 8 week trial of PPI and unresolved. Non-pharmacological: • First line treatment! Removing or modifying risk factors like coffee, spicy food, chocolate • small more frequent meals • sit up for 2 hours after meals • don’t eat 3-4 hours before going to bed. • Smoking cessation • Avoid alcohol Pharmacological: Omeprazole 20mg daily before breakfast/ PPI Follow up: 4-8 weeks for re-evaluation, if no relief high risk for Barrets Esophagus. Referral: None. GI after 8 weeks of PPI treatment with no relief, worsening of symptoms, or dysphagia. Differentials: • Cardiac disease • Esophageal spasm • Peptic ulcer disease • Asthma • Pulmonary edema Leik 267 Hollier:260