SmartSet Selection
What are the 3 hypertension smartset options?
Screening, Monitoring and treatment, and Incidental
You have a 28 year old female with stage 2 hypertension. Would lisinopril be an option for medication treatment for this patient?
Nope! Category D for pregnancy. Not for women who are pregnant or childbearing potential under age 60.
Patient has elevated cholesterol using cholestech machine, can we diagnose with elevated cholesterol?
No, must use venous draw for diagnosis.
Name 3 symptoms of hypothyroidism.
Fatigue, weight gain, hair loss, constipation
What are classic symptoms of hyperglycemia?
Polyuria, polydypsia, polyphagia and/or unexplained weight loss
A patient with NO history of hypertension presents for a DOT physical, the patient has elevated blood pressure today. After having a discussion with the patient you decide to start the treatment for blood pressure, what smartset would you use?
Screening
When would it be appropriate to recommend lifestyle modifications?
With EVERY patient!
Bonus: Name some lifestyle modifications
Age for statin initiation?
21 years old.
What labs would you order for symptomatic Thyroid screening and diagnosis?
TSH and Free T4
Bonus: if asymptomatic screening only, what lab would you order?
If a patient has those classic symptoms of polyuria, polydypsia, polyphagia and/or unexplained weight loss, and has a random plasma blood sugar of 234. What would we diagnose the patient with?
Diagnose with Diabetes due to syptoms + random plasma BS over 200
A patient with a history of hypertension presents with a cough and an elevated blood pressure. You note on the last visit his pressure was also elevated. How would you proceed?
Monitoring and Treatment
Name the ranges for Normal, elevated, stage 1 and stage 2 hypertension.
Normal BP: < 120 mm Hg and < 80 mm Hg
Elevated BP: 120-129 mm Hg and < 80 mmHg
Stage 1 Hypertension: 130-139 mm Hg or 80-90 mm Hg
Stage 2 Hypertension: ≥ 140/90 mm Hg or ≥ 90 mm Hg
What is the most common side effect with Statin therapy?
Muscle weakness, joint pain, fatigue
Bonus: What is a serious side effect that would cause you to stop the medication immediately?
What education would you give your patients regarding Levothroxine?
Take in morning on empty stomach, 60 minutes before food and not with coffee.
If a patient does not have classic symptoms, what is needed to diagnose a patient with diabetes?
Fasting plasma glucose (greater than 126) and plasma A1c (greater than 6.5%).
A patient with elevated blood pressure of 150/90 presents for an administrative physical. You discuss need for evaluation of hypertension and the patient refuses. What smart set do you choose?
Incidental Finding
In our setting, can we start the medication prior to having lab results?
NO!
Bonus: what lab is required prior to starting medications for hypertension?
Besides medication, what is something that can be done to lower cholesterol levels?
Lifestyle modifications:
dash diet, exercise, alcohol reduction, smoking cessation
You started a patient on Levothryoxine treatment, they are currently on 100mcg/day. They are back for a 6 week follow up visit. TSH remains elevated at 7.8. What would you increase the Levothryoxine dose to?
112mcg or 125mcg
Increase by 12.5-25mcg per day every 6-8 weeks until TSH is stable in normal range.
What is the most common side effect with Metformin?
GI upset, nausea, gas and bloating
A patient presents for an acute visit for sinusitis and also had a blood pressure monitoring visit completed. Which diagnosis is primary?
Sinusitis
Bonus: what smartset do you use for hypertension portion?
Patient presents with 2 day history of URI symptoms. Complains of mild congestion, headache, intermittent dizziness, and fatigue. Patient states that she gets sinus infections easily and needs a z-pack to "nip it in the bud." Her VS are: HR 97, R 20, BP 188/102, Temp 97.9, O2 sats 97%. What are your next steps?
Recheck BP, call 911
Bonus: Patient says "my blood pressure is always a little elevated, I am sure that this is all related to my sinus infection. Don't call 911." What do you do?
Name the labs that you should get prior to initiation of Statin therapy.
Fasting lipid panel, AST/ALT, BUN and Creatinine, Diabetes screen
Bonus: what labs are required for ongoing treatment?
There is a narrow therapeutic window on this medication and we would want to adjust carefully. What are some symptoms of hyperthyroid to watch for?
Rapid heart rate, sweating, angina, increased BP, dyspnea, muscle spasm, headache, anxiety, irritability, insomnia.
Thinking holistically, what are other screenings/services that we may want to offer to a diabetic patient?
Foot exam, recommend eye doctor visit, weight loss, smoking cessation, exercise, screening for cholesterol/hypertension/thyroid