NR 667 COMPREHESIVE GUIDE WITH COMPLETE SOLUTIONS

NR 667 COMPREHESIVE GUIDE WITH COMPLETE SOLUTIONS 1. Hypertension Presentation: Most are not symptomatic, Occipital Headaches, head ache 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 crosseson top of vein),papilledema • Kidneys: microalbuminuria and proteinuria,elevated serum creatinine and abnormaleGFR,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 ofopticfundi: Look for AV nicking, hemorrhage, papilledema • LVH (long standing HTN) • Perform exam ofsymmetrical pulses • Auscultatefor Carotid bruits, abdominal bruits, and kidney bruits Diagnosticstudies: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- yearrisk for heart disease (ASCVD) Diagnosis: 140/90 mm Hg starton B/Pmedication. Pharmacologic Management: • FIRSTLINE DIURETIC: Hydrochlorothiazide(HCTZ) 25 mg/day(max50mg/day) *May worsen gout and elevate lipids and glucose • ALTERNATIVE CCB: Amlodipine besylate 5 mg /day. (Watch for lower extremityedema) • ACE: lisinopril 10mg/day complicated HTN first line • Consider ACE/ARB in patient with DM, proteinuria, HF. CONTRAINDICATED INPREGNANCY • Ifstage 2, initiate 2 drug classes (Diuretic & CCB mosteffectivein AfricanAmerican) Follow up: • 2-4weeks Referral: • Cardiology ifEKG is abnormal Secondary HTN causes to consider: • CKD, renal arterystenosis, hyperthyroidism, phenochromocytoma, OSA,coartication of theheart (SBP higher in the legs), oral contraceptives, corticosteroids, cocaine, NSAID, decongestants Differential: • Secondary hypertension • Whitecoat syndrome • Pregnant • Pregnancyinduced hypertension Education: • First:Lifestyle modifications: diet and exercise30 minutes aerobicexercise 5 days perweek. • 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 • Reducesodium intake1,500 mg/day) • Measure BP daily, bring log to nextvisit, bring homecuff tocompareto office • Liek: 1 Hollier: 17, 1 2. Hyperlipidemia Presentation: Most patients are asymptomatic until they develop ASCVD. • Xanthomata (lipid deposits around theeyes) • Corneal Arcus prior to age 50 years (whiteiris), normal • Angina • Bruits • MI • Stroke Diagnostics: • Fasting/non-fasting lipid profile • Glucose, • UA and creatinine(for detection of nephroticsyndrome which can inducedyslipidemia), • TSH (for detection of hypothyroidism) • CMP Diagnosis: Optimal goal is 100 mg/dL Pt with LDL= 190mg/dL(without ASCVD or DM is a candidatefor high-intensity statin) Non-pharmacologic Management/Education: • FIRSTLINE: Lifestyle Modification; diet and exercise. • Diet toimproveserum lipids: Mediterranean diet, DASH,vegetarian, low-carb, andlow-trans fat. • Decreasesugar and simplecarbs • Avoid alcohol • Increasefish diet with Omega-3(salmon and sardines) twice a week • Weight loss • Aerobic typeexercise Pharmacologic Management: • FirstLine: Atorvastatin 10mg once a day at bedtime(perform liver function tests beforeinitiation therapy and then 4-6 and 12 weeks and after doseincrease). a) Low Intensity(lowersLDLon average by30%): 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. 1. Hypertension Presentation: Most are notsymptomatic, Occipital Headaches, headacheon awakening in am, burryvision. Look for theseclinical findings to ruleoutorgan damage: Microvascular • Eyes(HTN retinopathy): AV nicking (causes when arteriolecrosseson top of vein),papilledema • Kidneys: microalbuminuria and proteinuria,elevated serum creatinine and abnormaleGFR,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 ofopticfundi: Look for AV nicking, hemorrhage, papilledema • LVH (long standing HTN) • Perform exam ofsymmetrical pulses • Auscultatefor Carotid bruits, abdominal bruits, and kidney bruits Diagnosticstudies: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- yearrisk for heart disease (ASCVD) Diagnosis: 140/90 mm Hg starton B/Pmedication. Pharmacologic Management: • FIRSTLINE DIURETIC: Hydrochlorothiazide(HCTZ) 25 mg/day(max50mg/day) *May worsen gout and elevate lipids and glucose • ALTERNATIVE CCB: Amlodipine besylate 5 mg /day. (Watch for lower extremityedema) • ACE: lisinopril 10mg/day complicated HTN first line • Consider ACE/ARB in patient with DM, proteinuria, HF. CONTRAINDICATED INPREGNANCY • Ifstage 2, initiate 2 drug classes (Diuretic & CCB mosteffectivein AfricanAmerican) Follow up: • 2-4weeks Referral: • Cardiology ifEKG is abnormal Secondary HTN causes to consider: • CKD, renal arterystenosis, hyperthyroidism, phenochromocytoma, OSA,coartication of theheart (SBP higher in the legs), oral contraceptives, corticosteroids, cocaine, NSAID, decongestants Differential: • Secondary hypertension • Whitecoat syndrome • Pregnant • Pregnancyinduced hypertension Education: • First:Lifestyle modifications: diet and exercise30 minutes aerobicexercise 5 days perweek. • 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 • Reducesodium intake1,500 mg/day) • Measure BP daily, bring log to nextvisit, bring homecuff tocompareto office • Liek: 1 Hollier: 17, 1 2. Hyperlipidemia Presentation: Most patients are asymptomatic until they develop ASCVD. • Xanthomata (lipid deposits around theeyes) • Corneal Arcus prior to age 50 years (whiteiris), normal • Angina • Bruits • MI • Stroke Diagnostics: • Fasting/non-fasting lipid profile • Glucose, • UA and creatinine(for detection of nephroticsyndrome which can inducedyslipidemia), • TSH (for detection of hypothyroidism) • CMP Diagnosis: Optimal goal is 100 mg/dL Pt with LDL= 190mg/dL(without ASCVD or DM is a candidatefor high-intensity statin) Non-pharmacologic Management/Education: • FIRSTLINE: Lifestyle Modification; diet and exercise. • Diet toimproveserum lipids: Mediterranean diet, DASH,vegetarian, low-carb, andlow-trans fat. • Decreasesugar and simplecarbs • Avoid alcohol • Increasefish diet with Omega-3(salmon and sardines) twice a week • Weight loss • Aerobic typeexercise Pharmacologic Management: • FirstLine: Atorvastatin 10mg once a day at bedtime(perform liver function tests beforeinitiation therapy and then 4-6 and 12 weeks and after doseincrease). a) Low Intensity(lowersLDLon average by30%): 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.