PPP Exam 2 (1) PDF

Hypertension Physical Assessment:3 - Inspection - Palpation (use hands to feel body) - Percussion (striking the body) - Auscultation (listening) Normal Heart Rate : 60-100 bpm Respiratory rate: 12-20 bpm Blood Oxygen Saturation = SpO2 : 95-100% BP Formula: BP = CO x SVR CO - ca...

Hypertension Physical Assessment:3 - Inspection - Palpation (use hands to feel body) - Percussion (striking the body) - Auscultation (listening) Normal Heart Rate : 60-100 bpm Respiratory rate: 12-20 bpm Blood Oxygen Saturation = SpO2 : 95-100% BP Formula: BP = CO x SVR CO - cardiac output SVR - total resistance of arterioles to flow of blood Cardiac Output: CO = HR x SV HR = Heart rate SV = Stroke volume Temperature Systolic BP is the force of blood when your heart contracts and pumps blood out → Aortic pressure rises → Systemic arterial pressure rises Diastolic BP pressure is the force of blood when your heart rests between beats and fills with blood, relaxation → Aortic pressure falls → Systemic arterial pressure falls Heart disease & stroke is the leading cause of death in the US Primary Hypertension - 90-95% of hypertension cases - High BP in absense of known cause - Develops over many years Secondary Hypertension - 5-10% of hypertension cases - High BP w/ underlying, potentially correctible cause - Appears suddenly Often asymptomatic = “silent killer” Sometimes cause headache, dizziness, or blurred vision Screening - Adults 18+ - Annually for 40+, 3-5 yrs for 18-30 yrs - Increase risks include: - Elevated blood pressure - Obese - African american HTN target goal 25 Obese > 30 DASH = dietary approaches to stop hypertension Dietary Sodium 500mg/dl ❖ Low density lipoprotein cholesterol (LDL-C) TC-(HDL+TG/5) **Friedewald Equation ❖ High density lipoprotein cholesterol (HDL-C) ❖ Non-HDL cholesterol (Non-HDL-C) Only has atherogenic cholesterol prim/secondary target of therapy Useful when nonfasting lipid is obtained More predictive than LDL ❖ Others (VLDL, IDL, LP(a)) Screening Recs! 4-6 years in ages 20+ ○ More frequent for 40-75 yrs. More frequent for those with risk factors for high cholesterol Screening Methods 1. Lipid Panel a. Consists of TC, LDL, HDL, TG i. Invalid if TG>400 b. Proxy estimates ASCVD risk c. Non-fasting = look at HDL-C and non-HDL-C d. Fasting = look at LDL-C and TG  2. Estimate lifetime Risk ASCVD Risk Score - Asses risk of CHD, MI, and Stroke - Most accurate for african americans and white people 40-79 yrs. - 1- yr ASCVD risk score - 20% High 3. Assess Risk Factors High lipid biomarkers Triglycerides ≥175 mg/dL (persistently elevated) High-sensitivity C-reactive protein ≥2.0mg/dL Elevated lipoprotein (a) ≥50 mg/dL or ≥125 nmol/L Elevated apolipoprotein B ≥130 mg/dL Ankle-brachial index (ABI) ‹0.9 Metabolic syndrome - Factors that increase ASCVD and DM risk - Need 3+ risk factors Statins!! Primary Prevention - prevent/delay onset of ASCVD - Statins for… 1. LDL-C>190 2. LDL-C 70-189 mg/dl and elevated 10 yr. ASCVD risk (40-75 yrs.) 3. LDL-C 70-189 mg/dl w/ diabetes (40-75 yrs.) - Lifestyle recs. for… 1. LDL-C < 70 mg/dl 2. LDL-C 70-189 mg.dl and low ASCVD risk Secondary Prevention - Treat ASCVD & prevent repeat event - Statin therapy (high intensity) for.. 1. Clinic ASCVD a. Multiple ASCVD events b. 1 event and other risk conditions i. Heterozygous FH, hx of HF, CABG or PCI, DM, HTN, CKD< ❖ Cholesterol absorption inhibitors: ezetimibe (Zetia) ❖ Statins: rosuvastatin (Crestor)¥,atorvastatin (Lipitor)¥, simvastatin (Zocor)¥, lovastatin (Mevacor),pravastatin (Pravachol)¥, fluvastatin (Lescol), pitavastatin(Livalo) ❖ Bile acid sequestrants: cholestyramine (Questran), colestipol ( ❖ Colestid), Colesevelam (Welchol) ❖ Fibrates: fenofibrate (Tricor, Trilipix), gemfibrozil (Lopid)  ❖ Niacin (vitamin B3): Niaspan, Niacor ❖ Omega-3-acid ethyl esters: Lovaza, Epanova, Omtryg,Vascepa ❖ MTP inhibitor: Lomitapide(Juxtapid) ❖ Apoprotein B antisense oligonucleotide: Mipromersen (Kynamro) ❖ PSCK9 inhibitors: alirocumab (Praluent),evolocumab (Repatha) ❖ siRNA (PSCK9):inclisiran (Leqvio) ❖ ACL inhibitor: Bempedoic acid (Nexletol,Nexlizet) Diabetes Disease which body’s ability to produce/respond to insulin is impaired → results in abnormal metabolism of carbohydrates & elevated glucose in blood + urine = too much sugar in the blood! Regulation 1. Food intake 2. Elevated glucose 3. Stimulation of pancreas 4. Release insulin from beta cells (alpha cell for low glucose) 5. Insulin allows body to use glucose (fat cells take = high) (liver release = low) 6. Normal glucose levels Insulin = increase glucose uptake from blood to fat and muscle - In diabetes… not enoguh insulin or insulin resistance in fat and muscle Classifications: Type I Diabetes ○ Autoimmune B-cell destruction ○ Insulin Deficient ○ Accounts for 5-10% dx Type II Diabetes ○ Progressive loss of B-cell insulin secretion ○ Usually w/ glucose tolerance or insulin resistance ○ Accounts for 90-95% dx Gestational Diabetes (GDM)  ○ Onset during 2nd or 3rd trimester Diabetes due to other causes ○ Monogenic diabetes syndrome, disease of exocrine pancreas, drug/chemical induces Symptoms 3 - Ps ○ Polydipsia ○ Polyuria ○ Polyphagia Blurry VIsion Drowsiness Dry skin Slow healing wounds Fatigue Tingling, pain, numbness in hands/feet Complications Macrovascular - Cerebrovascular disease (stroke) - Coronary heart disease (MI) - Peripheral vascular disease (amputations) Microvascular - Retinopathy (blindness) - Nephropathy (kidney disease, end stage renal disease (ESRD)) - Autonomic neuropathy (gastroparesis, erectile dysfunction) - Peripheral Neuropathy (wounds, amputations) Screening ★ USPSTF ○ BMI >25 or obese BMI>30, age 35-70 ○ Screen earlier if they have 1 or more risk factors ★ ADA ○ Universal screening for 35 yrs+ ★ Every 3 years if normal glucose or every 1 for prediabetes Screening Assessment 1. Informal assessment of risk factors 2. standardized assessment tool (ADA risk test) 3. Measure fasting plasma glucose (FPG) or HBbA1c level, or use an oral glucose tolerance test (OGTT) Dx Criteria Fasting Plasma Glucose (impaired Fasting Glucose) - Preferred method - Measures sugar level after fasting for 8 hours RPG (Postprandial Plasma Glucose) - Can be used when not fasting - Blood sugar at the current point in time - Only diagnostic w/ classic symptoms of hyperglycemia or hyperglycemic crisis Hemoglobin A1C - Good for monitoring - Glucose w/ hemoglobin form glycosylated hemoglobin which stays in RBC till it dies - A1c measles glycated hemoglobin in RBCs - Reflects avg. glucose over the last 3 months - RBC have 120 day lifespan OGTT (Impaired glucose tolerance) - Secondary test; confirmation tool - Identify GDM - Fast for 8 hours - Consume 75g glucose - Collect sample 2 hours after glucose consumption (2hour post-prandial level) Severe Hyperglycemia Diabetic ketoacidosis (DKA) PG > 250 mg/dL Variable serum osmolarity pH < 7.3 Sodium bicarbonate < 15 mEq/L Elevated serum & urine ketones Fruity smelling breath Hyperosmolar hyperglycemic state (HHS) PG > 600 mg/dL Serum osmolarity > 320mOs m/kg pH > 7.3 Sodium bicarbonate > 15 mEq/L Mild or absent ketonemia Altered sensorium (stupor/com Rapid Acting - Insulin aspart (Novolog, Fiasp) - Insulin glulisine (Apidra) - Insulin lispro (Humalog) Short Acting (OTC) - Insulin regular (Novolin R, Humulin R)? Intermediate acting (OTC) - NPH (Novolin N, Humulin N) Long Acting - Insulin glargin (Landtus, TOujeo, Basaglar) - Insulin detemir (levemir) - Insulin degludec (tresiba) Glycemic Targets - A1c70 - Menopausal women - Adults w/ fracture - Adults w/ certain conditions or medications associated with low bone mass Lifestyle recommendations: - Ca+ - Vit. D - Smoking cessation - Reduce alchol/caffeine - Weight bearing exercise - Asses fall risk Calcium and Vitamin D Calccium - Absorbed in duodenum and jejunum - Vitamin D is required to absorb calcium in intestines - Sodium, protein, caffeine is bad for Ca balance - Lead to abnormal bone remodeling - Elemental calcium absorbed 500mg at time  *give calcium citrate for patients taking acid reducing drug Vitamin D - Fat soluble - Functions - Mineralized skeleton - Calcium metabolism/absorption - Regulate parathyroid hormone (PTH) - Ergocalciferol D2 - Cholecalciferol D3 - Hydroxylation of D2 after sun exposure Candidate for Rx medications: - hip/vertebral fracture - Fracture of pelvis, proximal humerus, or distal forearm - T-score