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 intake<1,500 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 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.


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 intake<1,500 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 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.