Brand New 2023 NR 667 Study Guide With Best Solutions

Brand New 2023 NR 667 Study Guide With Best Solutions

Liek: 1
Hollier: 17, 1
1. Hyperlipidemia
Presentation: Most patients are asymptomatic until they develop ASCVD.
• Xanthomata (lipid deposits around theeyes)
• Corneal Arcus prior to age 50 years (white iris),normal
• Angina
• Bruits
• MI
• Stroke
Diagnostics:
• Fasting/non-fasting lipidprofile
• Glucose,
• UA and creatinine (fordetectionofnephroticsyndrome whichcan
induce dyslipidemia),
• TSH (for detection ofhypothyroidism)
• 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 andexercise.
• Diet toimproveserum lipids: Mediterranean diet, DASH,vegetarian, low-carb,
and low-trans fat.
• Decrease sugar and simplecarbs
• Avoidalcohol
• Increase fish diet with Omega-3 (salmon and sardines) twice aweek
• Weight loss
• Aerobic typeexercise
Pharmacologic Management:
• FirstLine: Atorvastatin 10mgonceaday at bedtime(perform liver function tests
before initiation therapy and then 4-6 and 12 weeks and after doseincrease).
a) Low Intensity (lowers LDLon averageby <30%): Simvastatin 10mg, Pravastatin
10-20mg, Lovastatin 20mg
b) ModerateIntenstiy(lowers LDLonaverageby 30-49%): Atorvastatin 10-20mg
daily, Rosuvastatin 5-10mg, Simvastatin 20-40mg, Pravastatin 40-80mg.
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c) HighIntensity (lowers LDLonaverageby >50%): Atorvastatin 40-80mg
daily. (Never start on 80mg, always titrate up). Rosuvastatin 20-40mg.
• AVOID GRAPEFRUITJUICE! Watchforrhabdomylosis
• INTOLERANCETO STATIN: Alternative Welchol (Bile Acid Sequestrants) 625 mgtab
daily once aday.
• Age 21-75 high intensitytherapy
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
• Diabete
s
2. 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): AVnicking(causes whenarteriolecrossesontopof
vein), papilledema
• Kidneys: microalbuminuriaandproteinuria,elevatedserum creatinineand abnormal
eGFR, peripheral or generalized edema
Macrovascular
• Heart: S3 (CHF), S4(LVH),carotid bruits,decreased orabsentperipheral pulses
• Brain: TIA or hemorrhagicstroke
Assessment/Exam:
• Asymptomatic
• Occipitalheadache
• Blurry vision
• Headache upon wakening
• Exam ofopticfundi: Look for AVnicking,hemorrhage,papilledema
• LVH (long standing HTN)
• Perform exam of symmetricalpulses
• Auscultate for Carotid bruits, abdominal bruits, and kidneybruits
Diagnostic studies: EKG, fasting lipid profile, fasting blood glucose, TSH, CXR to R/O
cardiomegaly. CBC, CMP,andurinalysis. Measure BP 5 minutesapart. Assess thepatients 10-
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year risk for heart disease(ASCVD)
Diagnosis: > 140/90 mm Hg start on B/P medication.
Pharmacologic Management:
• FIRSTLINE DIURETIC: Hydrochlorothiazide (HCTZ)25 mg/day (max
50mg/day) *May worsen gout and elevate lipids and glucose
• ALTERNATIVE CCB: Amlodipinebesylate 5 mg /day. (Watch for lowerextremity
edema)
• ACE: lisinopril 10mg/day complicated HTN first line
• Consider ACE/ARB inpatient with DM,proteinuria, HF. CONTRAINDICATED IN
PREGNANCY
• Ifstage 2, initiate2drugclasses (Diuretic & CCB mosteffectivein
African American)
Follow up:
• 2-4weeks
Referral
:
• Cardiology if EKG isabnormal
Secondary HTN causes to consider:
• CKD, renalarterystenosis,hyperthyroidism,phenochromocytoma, OSA,coarticationof
the heart (SBP higher in the legs), oral contraceptives, corticosteroids, cocaine, NSAID,
decongestants
Differential:
• Secondaryhypertension
• White coatsyndrome
•
Pregnant
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• Pregnancy inducedhypertension
Education:
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•
• First: Lifestyle modifications:dietandexercise 30 minutesaerobic exercise 5
daysper week.
• Weight loss (BMI 25 andup)
• Limit alcohol (men:2 drinks or less per day; women: one drink or less perday)
• Stop smoking
• Stress management
• Eat fatty cold water fish (salmon, anchovy) 3x a week
• DASH
• Medicationcompliance
• Reduce sodium intake <1,500 mg/day)
• Measure BP daily,bringlogtonext visit, bringhomecuff tocompareto office
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, (showingsymptoms)
• agitation,
• nervousness,
• obesity,
• fatigue
• Chronic skininfections
• Women: chronic yeastinfection
• blurry vision
• Exam feet, pulses, nail thickness, odor, swelling,mobility
• Thyroidpalpitation
• Skinexam
Diagnostics: EKG, CBC, CMP, LIPIDS, Microalbuminuria, TSH, A1C
Diagnosis:
•
•
• Fasting between 100-126 = impaired
glucose Nonfasting less than 126 = normal
values
Fasting glucose>126mg/dl and confirmed on a differentday
Hgb A1C >or equal to 6.5%
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•
Non-pharmacologic Management:
• Monitor Blood glucose at home and diary(daily)
• Lifestyle modification: diet andExercise
• avoid alcohol
• avoid smoking
• Routine oralexams