Pediatric and Adult Health Assessment

Hypertension

• Blood pressure classification involves systolic and diastolic measurements in mmHg.
• Normal BP is <120 systolic and <80 diastolic.
• Borderline BP is 120-139 systolic and 80-89 diastolic.
• Hypertension is ≥140 systolic and ≥90 diastolic.

Proper Blood Pressure Measurement

• Measurement should occur in a seated position with the arm at heart level, using an appropriately sized cuff, after 5-10 minutes of relaxation.
• The cuff bladder's length should be 80% and its width 40% of the arm's circumference.
• A cuff that is too small will cause overestimation of BP.
• A cuff that is too large will cause underestimation of BP.
• Inflate the cuff to 30 mmHg above the expected systolic BP.
• Release pressure at 2-3 mmHg per second.

Blood Pressure Targets by Population

• The BP cut-off for diagnosis is ≥140/90 mmHg for the general adult population, elderly (≥80 years), diabetes mellitus, and chronic kidney disease (CKD).
• Treatment initiation BP cut-offs vary by population.
• General population: ≥140/90 mmHg.
• Elderly (≥80 years): ≥150/90 mmHg.
• Acute Ischemic Stroke (AIS) requires <185/110 mmHg before thrombolysis.
• Intracerebral Hemorrhage (ICH) diagnosis requires ≥180 mmHg.
• Pregnancy (severe hypertension) diagnosis requires ≥160/110 mmHg.
• Pregnancy (non-severe hypertension) diagnosis requires ≥140/90 mmHg.
• Pediatric Population (General) requires diagnosis at ≥90th percentile for age, sex, and height.
• Pediatric Population (Adolescents ≥13 years) needs persistent hypertension.
• Pediatric CKD Patients need persistent hypertension.
• General population target is <130/80 mmHg.
• Elderly (≥80 years) should have a target BP <140/90 mmHg.
• Diabetes Mellitus target is <130/80 mmHg.
• Chronic Kidney Disease (CKD) target is <130/80 mmHg (high-risk).
• Acute Ischemic Stroke (AIS) target is <180/105 mmHg after thrombolysis.
• Intracerebral Hemorrhage (ICH) target is 140-160 mmHg.
• Pregnancy (severe hypertension) target is <140/90 mmHg.
• Pregnancy (non-severe hypertension) target is <140/90 mmHg for those with co-morbidities.
• Pediatric Population (General) target is <90th percentile for age, sex, and height.
• Pediatric Population (Adolescents ≥13 years) target is <120/80 mmHg.
• Pediatric CKD Patients target is ≤50th percentile for age, sex, and height.

General Hypertension Management

• Step 1: Lifestyle modifications.
• Step 2: Initiate monotherapy with ACE-I, ARB, CCB, or Thiazide.
• Step 3: Utilize combination therapy if monotherapy fails.
• Step 4: Refer to specialist if hypertension is resistant, meaning uncontrolled on ≥3 drugs, including diuretics.

Non-Pharmacologic Management for Hypertension

• Sodium Restriction: Recommended intake: <1,500 mg/day; upper limit: 2,300 mg/day.
• DASH Diet: High in fruits, vegetables, low-fat dairy; low in saturated fats and sweetened foods.
• Physical Activity: Moderate aerobic exercise for at least 150 minutes per week, plus resistance exercises twice weekly.
• Alcohol Intake: Moderate: ≤2 drinks/day (men) and ≤1 drink/day (women).
• Weight Management: Aim for ≥5% weight loss for overweight or obese individuals.
• Smoking Cessation: Avoid active and passive smoking.

Pharmacologic Management

• First-line options for general adults include ACE-I/ARB, CCB, and thiazides.
• Avoid combining ACE-I and ARB.
• For Diabetes, ACE-I/ARB + CCB/Thiazide should be used, avoid lowering BP too much meaning avoid a BP <120/70 mmHg.
• For CKD, ACE-I/ARB drugs are important but monitor proteinuria, and avoid combining ARB + ACE-I.
• Pregnancy: Methyldopa, CCB, Beta-blockers is the recommendation, and avoid ACE-I, ARB.

Blood Pressure Targets

• General population: <130/80 mmHg.
• Elderly (≥80 years old): <140/90 mmHg.

When to Refer

• Refer for Resistant Hypertension: The BP remains ≥140/90 despite 3-drug therapy, specialist referral for secondary causes.

Patient Education

• Self-Monitoring of Blood Pressure (SMBP): Educate on checking BP at home daily.
• Medication Adherence: Inform patient of consequences for skipping doses.
• Recognizing Hypertensive Urgency: Educate on when to seek immediate care.
• Follow-Up Plan: Reassess BP in 2-4 weeks and increase dose or if not controlled, add second-line medication.

Diabetes Diagnostic Criteria

• Fasting Plasma Glucose (FPG): Diabetes is indicated by ≥126 mg/dL, prediabetes by 100-125 mg/dL, normal is less than <100 mg/dL.
• 2-Hour Plasma Glucose (OGTT): Diabetes is indicated by ≥200 mg/dL, prediabetes 140-199 mg/dL, and normal by <140 mg/dL.
• A1C: Diabetes is indicated by ≥6.5%, prediabetes 5.7%-6.4%, and normal by <5.7%.
• Random Plasma Glucose: Diabetes is indicated by ≥200 mg/dL (with symptoms).

Glycemic Targets

• Non-Pregnant Adults Goal: <7% (53 mmol/mol), Less stringent,
• Stricter diabetes regulation requires intensive monitoring and frequent therapy adjustments, whereas relaxation of previous restrictions are appropriate in patients with multiple comorbidities
• Pregnant Women with diabetes Goal: <6% (42 mmol/mol)

Initial Risk Stratification

• Management Approach: Lifestyle modification first
• Lifestyle modification first : Preferred choice are metformin, GLP-1 RA, SGLT2i
• Atherosclerotic Cardiovascular Disease (ASCVD): Prefer GLP-1 RA or SGLT2i
• Heart Failure (HF) or CKD (eGFR <60 ml/min/1.73m²): SGLT2i preferred
• Severe hyperglycemia (HbA1c ≥9%): Considers dual therapy or insulin
• HbA1c ≥10%, blood glucose >300 mg/dL: Start insulin immediately.

Treatment Selection Based on Patient Profile

• No comorbidities Preferred choice is Metformin Alternative is GLP-1 RA, SGLT2i
• ASCVD dominant GLP-1 RA (e.g., semaglutide, liraglutideCombination therapy if HbA1c remains high SGLT2i (empagliflozin, combination is therapy if HbA1c remains high or SGLT2

Management

• Heart failure or CKD :If SGLT2i (empagliflozin, d not tolerated: GLP-1 RA
• Need for weight loss: GLP-1 RA, SGLT2i
• Hypoglycemia risk (elderly,.renal disease) GLP-1 RA, SGLT2i DPP-4 inhibitors
• Cost concerns Metformin. Sulfonylureas (glimepiride, gliclazide), TZDs (

Treatment

• Adjust treatment every 3 months based on HbA1c response.
• Initial Dose: 500 mg OD, and then Increase weekly by 500 mg to 2000 SGLT2i (e.g., empagliflozin, dapagliflozin)Can increase based on renal function, for Empa 10 mg, Dapa 5 mg QD Avoid if eGFR <30
• Monitor blood glucose levels , and then Adjust insulin doses based on fasting and postprandial glucose.

Indications for Insulin Therapy

• Severe hyperglycemia or Symptomatic hyperglycemia Failure of oral therapy: remains with higher or equal HbA1c Acute illness, pregnancy
• Severe infection or stress state .
• Acute illness, pregnancy, surgery, or hospitalization, with CKD stage 4-5

Insulin Regimen

• how to start for Preferred Basal InsulinsLonger and Intermediate-acting
• Titrate basal insulin every 3 days based on blood glucose targets:Increase and Reduce by units and reduce glucose

How to Start Prandial (Mealtime) Insulin

-Indications: Postprandial glucose >180 mg/dL, HbA1c >8% despite basal insulin -Preferred Insulins: Rapid-acting (Aspart, Lispro, Glulisine) -Titrate every 3 days based on 2-hour postprandial glucose:

• Each reading should Increase or reduce by amount base on range

Full Basal-Bolus Regimen

• Used for people having (For HbA1c ≥10%)
• Start with: Start Basal dosing- then add Bolus: adjust

How to Start Prandial (Mealtime

• Every teaching point requires Rotation sites
• Storage requires to Keep unopened in fridge

Non-Pharmacologic Management

• Diet- Low-carb, high-fiber diet and then reduce refined sugars with saturated fats
• Exercise Requires 150 mins a week of moderate intensity
• Weight loss requires Target 5-10%
• Alcohol requires Limit to ≤1 and 2 drinks/day depending on male or femal

Follow monitoring

• HbalC, lipids, blood pressure, yearly checks for neuropathy and kidney asssments are crucial to monitor

Diabetes mellitus

• Confirm Diagnosis
• Diagnostic Test Criteria for Diabetes Test the urine for protein in a urine test
• Adjust the medications based on HbA1c every 3 months.

Preventing Hypoglycemia:

• Avoid sulfonylureas (e.g., glibenclamide) in elderly due to high risk of hypoglycemia.

Guidelines for Red Flags

• Red Flags : Symptoms of diabetic ketoacidosis, or Severe hyperglycemia are an immediate concern

Patient Education and Follow-Up:

• Patient educations such as Self-Monitoring of Blood Glucose are important Preventing Hypoglycemia:
• Avoid sulfonylureas in elderly due to high risk of hypoglycemia.
• Reassess HbA1c every 3 months.
• Monitor for diabetes complications annually Adjust medications as needed based on glycemic trends and risk factors.

Bronchial Asthma

• Spirometry and peak monitoring are important
• Elevated FeNO indicates air inflammation

Symptoms:

• Intermittents needs low dose ICS or formetorol
• Persistents daily, no need to take low dose IS or formetorol

Asthma Education

• Avoid irritants, do breathing excercises
• Written action plan for medical emergencies is important

Acute Exacerbations

• Mild to Moderate is typically resolved
• Severe- call 811 and follow steps for breathing managment:
• Salbutamol puffs
• Prednisolone for 5-7 days, along with 93-95 oxygen therapy

Guidelines for Red Flags

• Red Flags :severe talking problems, altered mental status, low oxygen sats.

Chronic Obstructive Pulmonary Disease (COPD)

• Spirometry results are as follows are :confirm diagnosis of COPD: FEV1/FVC < 0.70 confirms airflow limitation.This differentiates COPD from asthma.
• Assess the Degree of Airflow: Assess the Degree of Airflow LimitationAssess by chart
• Assess symptom Burden: Assess Symptoms via A,B,E chart

Goals of COPD treatment

• GOLD 1: SABA or SAMA as needed
• GOLD 2: LABA or LAMA GOLD 3: LABA + LAMA (Consider ICS if eosinophils ≥300 cells/μL)

Guidelines for Red Flags

• Red Flags :worsning, or new condition

Summary for COPD

1. Confirm diagnosis of COPD
2. Assess Airflow result
3. Assess Sypmtoms via mARC

Smoking Cessation

• Ask about history of smoking
• Formula for smoking: packs a day times years
• use a nicotine dependence or withdrawal dependence scale
• Always ask if want to quit smoking
• Use Fagerstrom Test for Nicotine Dependence
• Always try the the 5 A's : Ask, Advise, Assess, Assist, and Arrange.

Guidelines for Smokng

• Nicotine Dependence : 21 mgg for 10+ cigarettes, and gum for 2-4 gm cigarette pack
• Follow up with doctor
• Always identify triggers or coming strategies to try with dependence
• Offer long term support

Key Points for Smoking

• Low dependence: use interviewing and talking to them of the benefits
• Moderate, use nicotine patches, gums and losengers
• High dependence: use the higher end nicotine products, which can also be combined together
• Follow up is important

###Dyslipidemia

• Diagnostic for LDL is ≥130 mg/dL
• HDL - <40 mg/dL men <50 mg/dL women
• Total Cholesterols (TC) <100 mg/dL
• Treatment and indications are based on above numbers and can be found with chart, using low fats and high colesterols

Guidelines for Checkups

• Check for cholesterol, AST/ALT every 1-2 months for side effect monitoring
• Follow up every 6-8 weeks for response

Diagnoses

• History of MI or stroke
• History or diabetes or high blood pressure

General Overview Pneumonia

: Mild : no significants comorbidities, and have stable vilitals :Moderateterm-20e: presence of comorbidites and age over 60 term : Severe : Requires mechanical ventilation

General Tests

Sputum and blood tests are done to see origin Antibiotics and antifungals are given

Guidelines For Pneumonia

Severity First-Line Antibiotics, some are amoxicillin, and azithyocin

Post exposure to Pneumonia

One time vacine at the minimum PCV20 Consider the patients history Symptoms to check are shortness of breath, chest pains, etc

Diagnostic Tests

Assess Lung Function : Pre-bronchodilator FEV1/FVC < 70%.

• FEV1 increase of >12% and >200mL after bronchodilator
• Check for family allergy history or expose

Guidelines for Classification

Intermittent : normal and greater equal 80% function

• Persistent : non, requires regular monitoring, and functions are at average percentage that required more attention to
• Red flags are common like accessory muscles or altered mental status

Pediatric Pnuemonia

Primary symptoms range, also note the crackles

• Assess with diagnostic test and chart Most signs will have fever or difficulty breathing. Check if there is an infection as well

Classification

• In order to classify at higher risk, it requires 2 vairables (Ex xray, O2, Saturation

Management Techniques

Support and provide a clean and bacteria free route to help treat

• For antibiotics there will be amoxicillin or alt Duration of treatment depends how severe and what bacteria

Pnuemonia Guidellines

• Know the test well and how to diagnose
• Be able to help get the child to feel better, and have the parents relax to
• Red flags are not as common

Rabies

First, confirm with question and answer Greets the patient and assess to establish that everything is right

• Ask when did it happen and how the bite happened  Does this pt need a vaccine and if so TT/Td?
• There shojld be a proper wash, around running time and what steps to take for if this doesn't work

Guidelines for Infection/Rabies

• Follow the chart to see if test and vaccine are needed, it depends the wound, animal, and medical condition
• Review 3 types of cat rabies, Manage and follow up for proper check-up

###Guidelines Tetanus

• assess 3 doses of the vaccine
• Assess minor versus not minor is
• Assess is vaccine needed and provide education

Tetanus Vaccine Guidlines

• Need 3 doses of booster vaccine
• If not and it hurts a lot, that leads to not fun problems _ red flags show deep cuts
• Tdap once, then Td every 10 years ✓ High-risk patients Prioritize RSV and PCV vaccines. High Risk: RSV, pneumonia, death, comorbidities Annual and One time vaccines

Childhood Immunization

• Follow up for every 6 months for any child that has had a dose
• If there is 95% at both times, it means they got all the needed vaccines and no more is neede
• In this field, you're dealing with childern and the parents are already worried

Thyroid Examination

• Palpate is required: Thyroid Examination: Inspect and palpate the thyroid gland for enlargement, nodules, or tenderness.
• Eyes will also show what there wrong
• Thyroid Ultrasound: If structural abnormalities are suspected is a sign that there is a larger problem In order to be treated. Must follow 2 steps

Hyperthyroidism

Pharmacological Treatment: Methimazole (MMI): Preferred due to once-daily dosing and Non-Pharmacological Treatment Surgery: Subtotal or total thyroidectomy in cases of malignancy suspicion.

Hypothyroidism

• Levothyroxine is the main form
• Low and stable testing has to be done often Follow red flag :hypothermia and slow breathing

Heart Failure

• You can assess it by finding out prior history
• You first determine the heart disease and you follow the test to check
• After you listen, you can treat

###Heart Failure Treatment

• Follow the proper levels and asses