1
1. Hypertension
Presentation: Most are not symptomatic, Occipital Headaches, headache on awakening in am,
blurry vision,
Assessment:
• Asymptomatic
• Occipital headache
• Blurry vision
• Headache upon wakening
• Look for AV nicking
• LVH
Exam:
• Carotid bruits
• Abdominal bruits
• Kidney bruits
Diagnostic studies: to look for secondary causes of HTN like target organ damage and establish
ASCVD risk: EKG, fasting lipid profile, fasting blood glucose, CBC, CMP (electrolyte,
creatinine, & calcium levels), and urinalysis (checking for proteinuria).
Diagnosis: Measure BP 5 minutes apart. Average of 2 or more BP readings on two different
visits at > 140/90 mm Hg start then can be diagnosed with HTN.
If Stage 1 (ASCVD <10%) then non-pharmacologic management only:
• First: Lifestyle modifications: diet and exercise 30 minutes aerobic exercise 5
days per week.
• Limit alcohol
• stop smoking
• stress management.
• DASH
• Medication compliance
• Reduce sodium intake
• Measure BP daily
If Stage 2 (ASCVD >10% and known CAD) initiate lifestyle + Pharmacologic
Management:
• Alone: hydrochlorothiazide (HCTZ) 25 mg/day (chlorthalidone is preferred over
HCTZ)
• Alone: lisinopril 10mg/day complicated HTN first line
• Combo: thiazide + ACE or ARB
• Alternative CB (especially in isolated HTN seen mainly in older adults)
• Black population: thiazide + CCB is recommended first line
Follow up:
• 2-4weeks
Referral:
• Cardiology if EKG is abnormal
Differential:
• Secondary hypertension
• Pregnant
• Pregnancy induced hypertension
Hollier: page 62
, 2
2. Hyperlipidemia
Etiology: may be familial, dietary, obesity, hypothyroid, renal disorders, thiazide or beta blocker
use, alcohol and/or caffeine intake
Presentation: few physical findings
• Xanthomata (lipid deposits around the eyes)
• Corneal Arcus prior to age 50 years (white iris), normal
• Angina
• Bruits
• MI
• Stroke
Diagnostics:
• Fasting/nonfasting lipid profile (total cholesterol, LDL, and HDL
minimally affected by eating)
• Glucose,
• UA and creatinine (for detection of nephrotic syndrome which can
induce dyslipidemia),
• TSH (for detection of hypothyroidism)
Diagnosis: Pt with LDL >= 190mg/dL
Non-pharmacologic Management:
• Lifestyle Modification; diet and exercise.
Pharmacologic Management
Those who benefit most from statin therapy include:
• hx of CVD or stroke,
• LDL 190 or greater,
• DM with LDL 70-189,
• no evidence of ASCVD or DM but have LDL 70-189 PLUS an estimated ASCVD risk
of 7% or greater
• High risk:
o Atorvastatin 40 or 80 mg daily
o Rosuvastatin 20 or 40 mg daily
• Moderate risk:
o Atorvastatin 10 or 20 mg daily
o (other statin medications also listed in Hollier)
• If statins not tolerated, temporarily stop, decrease dose, and re-challenge with 2-3 statins of
differing metabolic pathways and intensities.
Follow up:
• after initiating therapy, follow-up every 6-8 weeks until goal attained then every 6-
12 months to evaluate compliance
• evaluate lipids every 5 years starting at age 20 if normal values obtained
Refer: Nutritionist
Differentials: consider secondary causes
• Hypothyroidism
• Pregnancy
• Diabetes
• Non-fasting state
Hollier: page 55
,3
3. Diabetes type 2 -
Etiology: genetics, high BMI with central obesity, inactivity, drug or chemical induced like
glucocorticoids or antiretroviral therapy
Risk factors:
• BMI >/= 25
• Hx of gestational diabetes
• First or second degree relative with DM
• PCOS, acanthosis nigricans
• HDL-C <35 / TG >250
• HTN or HTN treatment meds
• CVD
Presentation (assessment): insulin resistance in target tissues
• Polydipsia, Polyuria, Polyphagia, (showing symptoms)
• agitation,
• nervousness,
• obesity,
• fatigue
• blurry vision
• Exam feet, pulses, nail thickness, odor, swelling, mobility
Diagnostics: EKG, CBC and urinalysis (glucosuria, proteinuria, hyperglycemia), CMP, LIPIDS<
Microalbuminuria, TSH, A1C
Diagnosis:
• Diabetes
• 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/prevention:
• Weight loss (5-10 pound goal)
• Monitor Blood glucose at home and diary (daily)
• Exercise 150 minutes or more per week (no more than 2 consecutive days without
activity); resistance training 2-3 days per week on nonconsecutive days
• avoid alcohol
• avoid smoking
Pharmacologic Management:
• First: Initiate metformin 500mg BID if not contraindicated, then, when needed add-
• Actos 15 mg daily, then, when needed add-
• Levemir 10 units once a day
• *Initiate insulin early in course of oral therapy: 0.1-0.2 units/kg/day or 10 units daily of
peakless insulin
• With older adults, start low and go slow
Follow up:
• recheck A1C in 90 days
• Screening in adults >45 years be done every 3 years and ore often if fasting glucose close
to 126
, 4
• Screen patients with hx of gestational diabetes at 6-12 weeks gestation with OGTT
and Q3years after that for life
Referral:
• Ophthalmologist at time of diagnosis
• Fundoscopic exam
• Diabetic educator/ specialist
• Podiatry
Education:
• Carbs 50%
• Protein 30%
• Fat 20%
• Good glycemic control – no low sugars
• 10-15 years develop complications
Complications (usually present within 10-15 years after onset of DM but may earlier):
• Neuropathy
• Nephropathy
• Glaucoma = blindness
• Cataracts
• Charcot foot
Differentials:
• Gestational diabetes
• Cushing’s syndrome
• Corticosteroid use
Hollier: page 216
4. Back pain –
Etiology: often unable to pinpoint; may be due to stretching or tearing of nerves (radiculopathy),
muscles, tendons, ligaments, or fascia of the back secondary to trauma or just chronic
mechanical stress; compression or irritation of the nerve roots are common
Presentation:
• back pain complaint, buttock or one or more thighs that is aggravated by movement,
rising from seated positions, standing, and flexion (may be relieved by rest)
• muscle spasm may be present over lumbosacral area
• Maybe localized, referred, or radiating (down leg and below knee)
• Assess rectal tone in those describing cauda equina
• Motor, sensory, and reflex exams should be done
o DTRs: patellar tests nerve roots at L2-L4 & Achilles tests nerve roots at S1-S2
o Diminished or absent imply myopathies, decreased muscle mass, and nerve
root impairment
• New onset of radicular pain on older adults is often sign of spinal stenosis
• Straight leg raise test: elevation of affected leg in supine will elicit pain at 20-
30 degrees for severe disease, 30-60 degrees for moderate.
• Determine OLDCARTS, any pre-existing conditions, past surgeries or trauma
which may be contributing.
Diagnostics: (see imaging below)
1. Hypertension
Presentation: Most are not symptomatic, Occipital Headaches, headache on awakening in am,
blurry vision,
Assessment:
• Asymptomatic
• Occipital headache
• Blurry vision
• Headache upon wakening
• Look for AV nicking
• LVH
Exam:
• Carotid bruits
• Abdominal bruits
• Kidney bruits
Diagnostic studies: to look for secondary causes of HTN like target organ damage and establish
ASCVD risk: EKG, fasting lipid profile, fasting blood glucose, CBC, CMP (electrolyte,
creatinine, & calcium levels), and urinalysis (checking for proteinuria).
Diagnosis: Measure BP 5 minutes apart. Average of 2 or more BP readings on two different
visits at > 140/90 mm Hg start then can be diagnosed with HTN.
If Stage 1 (ASCVD <10%) then non-pharmacologic management only:
• First: Lifestyle modifications: diet and exercise 30 minutes aerobic exercise 5
days per week.
• Limit alcohol
• stop smoking
• stress management.
• DASH
• Medication compliance
• Reduce sodium intake
• Measure BP daily
If Stage 2 (ASCVD >10% and known CAD) initiate lifestyle + Pharmacologic
Management:
• Alone: hydrochlorothiazide (HCTZ) 25 mg/day (chlorthalidone is preferred over
HCTZ)
• Alone: lisinopril 10mg/day complicated HTN first line
• Combo: thiazide + ACE or ARB
• Alternative CB (especially in isolated HTN seen mainly in older adults)
• Black population: thiazide + CCB is recommended first line
Follow up:
• 2-4weeks
Referral:
• Cardiology if EKG is abnormal
Differential:
• Secondary hypertension
• Pregnant
• Pregnancy induced hypertension
Hollier: page 62
, 2
2. Hyperlipidemia
Etiology: may be familial, dietary, obesity, hypothyroid, renal disorders, thiazide or beta blocker
use, alcohol and/or caffeine intake
Presentation: few physical findings
• Xanthomata (lipid deposits around the eyes)
• Corneal Arcus prior to age 50 years (white iris), normal
• Angina
• Bruits
• MI
• Stroke
Diagnostics:
• Fasting/nonfasting lipid profile (total cholesterol, LDL, and HDL
minimally affected by eating)
• Glucose,
• UA and creatinine (for detection of nephrotic syndrome which can
induce dyslipidemia),
• TSH (for detection of hypothyroidism)
Diagnosis: Pt with LDL >= 190mg/dL
Non-pharmacologic Management:
• Lifestyle Modification; diet and exercise.
Pharmacologic Management
Those who benefit most from statin therapy include:
• hx of CVD or stroke,
• LDL 190 or greater,
• DM with LDL 70-189,
• no evidence of ASCVD or DM but have LDL 70-189 PLUS an estimated ASCVD risk
of 7% or greater
• High risk:
o Atorvastatin 40 or 80 mg daily
o Rosuvastatin 20 or 40 mg daily
• Moderate risk:
o Atorvastatin 10 or 20 mg daily
o (other statin medications also listed in Hollier)
• If statins not tolerated, temporarily stop, decrease dose, and re-challenge with 2-3 statins of
differing metabolic pathways and intensities.
Follow up:
• after initiating therapy, follow-up every 6-8 weeks until goal attained then every 6-
12 months to evaluate compliance
• evaluate lipids every 5 years starting at age 20 if normal values obtained
Refer: Nutritionist
Differentials: consider secondary causes
• Hypothyroidism
• Pregnancy
• Diabetes
• Non-fasting state
Hollier: page 55
,3
3. Diabetes type 2 -
Etiology: genetics, high BMI with central obesity, inactivity, drug or chemical induced like
glucocorticoids or antiretroviral therapy
Risk factors:
• BMI >/= 25
• Hx of gestational diabetes
• First or second degree relative with DM
• PCOS, acanthosis nigricans
• HDL-C <35 / TG >250
• HTN or HTN treatment meds
• CVD
Presentation (assessment): insulin resistance in target tissues
• Polydipsia, Polyuria, Polyphagia, (showing symptoms)
• agitation,
• nervousness,
• obesity,
• fatigue
• blurry vision
• Exam feet, pulses, nail thickness, odor, swelling, mobility
Diagnostics: EKG, CBC and urinalysis (glucosuria, proteinuria, hyperglycemia), CMP, LIPIDS<
Microalbuminuria, TSH, A1C
Diagnosis:
• Diabetes
• 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/prevention:
• Weight loss (5-10 pound goal)
• Monitor Blood glucose at home and diary (daily)
• Exercise 150 minutes or more per week (no more than 2 consecutive days without
activity); resistance training 2-3 days per week on nonconsecutive days
• avoid alcohol
• avoid smoking
Pharmacologic Management:
• First: Initiate metformin 500mg BID if not contraindicated, then, when needed add-
• Actos 15 mg daily, then, when needed add-
• Levemir 10 units once a day
• *Initiate insulin early in course of oral therapy: 0.1-0.2 units/kg/day or 10 units daily of
peakless insulin
• With older adults, start low and go slow
Follow up:
• recheck A1C in 90 days
• Screening in adults >45 years be done every 3 years and ore often if fasting glucose close
to 126
, 4
• Screen patients with hx of gestational diabetes at 6-12 weeks gestation with OGTT
and Q3years after that for life
Referral:
• Ophthalmologist at time of diagnosis
• Fundoscopic exam
• Diabetic educator/ specialist
• Podiatry
Education:
• Carbs 50%
• Protein 30%
• Fat 20%
• Good glycemic control – no low sugars
• 10-15 years develop complications
Complications (usually present within 10-15 years after onset of DM but may earlier):
• Neuropathy
• Nephropathy
• Glaucoma = blindness
• Cataracts
• Charcot foot
Differentials:
• Gestational diabetes
• Cushing’s syndrome
• Corticosteroid use
Hollier: page 216
4. Back pain –
Etiology: often unable to pinpoint; may be due to stretching or tearing of nerves (radiculopathy),
muscles, tendons, ligaments, or fascia of the back secondary to trauma or just chronic
mechanical stress; compression or irritation of the nerve roots are common
Presentation:
• back pain complaint, buttock or one or more thighs that is aggravated by movement,
rising from seated positions, standing, and flexion (may be relieved by rest)
• muscle spasm may be present over lumbosacral area
• Maybe localized, referred, or radiating (down leg and below knee)
• Assess rectal tone in those describing cauda equina
• Motor, sensory, and reflex exams should be done
o DTRs: patellar tests nerve roots at L2-L4 & Achilles tests nerve roots at S1-S2
o Diminished or absent imply myopathies, decreased muscle mass, and nerve
root impairment
• New onset of radicular pain on older adults is often sign of spinal stenosis
• Straight leg raise test: elevation of affected leg in supine will elicit pain at 20-
30 degrees for severe disease, 30-60 degrees for moderate.
• Determine OLDCARTS, any pre-existing conditions, past surgeries or trauma
which may be contributing.
Diagnostics: (see imaging below)
