Dr neil jaddou m. D board certified and professor of family medicine



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SOMERSET FAMILY MEDICINE CLINICAL MODULE ‘The Bread and Butter of Family Medicine’



DR NEIL JADDOU M.D BOARD CERTIFIED AND PROFESSOR OF FAMILY MEDICINE

Somerset Family Medicine

36950 Ryan Rd

Sterling Heights

MI 48310




WELCOME!




Welcome to Dr Neil Jaddou’s Externship Program!

This is a brief manual to

The Bread and Butter of Family Medicine’.



In this manual, the most common pathologies are discussed.

Not only will you will have a better understanding of their presentation,

you will also learn the latest recommended guidelines on how to treat them.

Enjoy!



CONTENT
1 . HYPERTENSION --------------------------------------PG 3-14

2 . DIABETES DISORDERS -----------------------------PG 15-20

3 . BLOOD CHOLESTEROL AND ATHEROSCLEROTIC

CADIOVASCULAR DISEASEPG ------------------------PG21 -28

4 . ANTIBIOTICS- -----------------------------------------PG 29-35

5 . ASTHMA--------------------------------------------------PG 36-43

6 . THYROID DISORDERS -----------------------------PG 44-50

7 . GOUT -----------------------------------------------------PG 51-55

8 . ALLERGIC RHINITIS -------------------------------PG 56-57

9 . MIGRANE-----------------------------------------------PG 58-75

10. SKIN RASH----------------------------------------------PG 76-85

11. PAIN MANAGEMENT-------------------------------PG 86-90

12. CONSTIPATION--------------------------------------PG 91-95

13. SMOKING CESSATION-----------------------------PG 96-103
Somerset Family Medicine Clinical Module

Bread & Butter of Family Medicine:

Hypertension
Prevelance: Most common chronic condition. Over 60% of elderly have HTN, more common and more severe in African Americans.

Without treatment approximately many will die of CAD, CHF, CVA and renal failure.



Etiology: Majority caused by unknown reason or hereditary, Essential or Idiopathic HTN (90-95%), while 5-10% of cases are due to other causes

Secondary causes: Hyperthyroidism, hyperaldosteronism, pheochromocytoma (epin and norepinephrine, Cushing, sleep apnea and renal artery stenosis.

Meds that increase BP: pseudoephedrine, OCP, NSAIDS, opiates, cocaine and energy drinks.
CLINICAL PRESENTATION:

Usually asymptomatic (silent killer) discovered during routine medical care, but severe HTN may present with headache, dizziness, SOB or blurred vision.


COMPLICATIONS OF CHRONIC HYPERTENSION:

1.Left Ventricular Dysfunction: Due to increased afterload, the left ventricle has to accommodate by increasing its diameters concentrically leading to Concentric left ventricular hypertrophy which can be detected on EKG, on the long run, the hypertrophied LV becomes stiff and Diastolic failure occurs which manifests as S4, eventually Systolic dysfunction ensues if HTN is not controlled.
2. Vascular disease: HTN accelerates atherosclerosis and is considered the most common risk factor for ischemic heart disease, and is a risk factor for both ischemic and hemorrhagic strokes.
3. Hypertensive Retinopathy & NephropathyLeading to eye problems and renal failure.
DIAGNOSTIC TESTS: UA, EKG, Metabolic panel, Lipid panel.

Routine tests for hypertension cases are:


Treatment: JNC guidelines vs standard of care, you may or may not follow guidelines but you must follow standard of care.

Erectile dysfunction: Beta blocker and Diuretics (although others may as well)

IF risks eliminated, consider tapering off. i.e., patient looses 30lb etc
NONPHARMICOLOGICAL MEASURES

  • Follow DASH diet (low fat, low salt, fruit & veg, grains, lean meat, fish, chicken)

  • Exercise

  • stress and anger management (Relaxation techniques)

  • Weight loss (10-15% wt)

  • smoking cessation, limit alcohol intake, decrease excess caffeine such as energy drinks.

Q/What is the most effective lifestyle modification for hypertension?

Answer: Weight loss

If lifestyle modifications have no effect over 3-6 months, initiate medical

therapy:
Pharmacology:
Use a thiazide diuretic, such as hydrochlorothiazide or chlorthalidone.

In diabetics, however, use ACEI/ARB as the first-line therapy.

About 70 percent of patients will be controlled with a diuretic alone. If pressure

control is not achieved with a diuretic alone, add a second drug:

Beta blocker (atenolol, metoprolol)

ACE inhibitor

Angiotensin receptor blocker (ARB)

Calcium channel blocker (CCB)

About 90-95 percent of patients should achieve control with the use of 2 medications.

If 2 drugs do not work, add a third drug and investigate for causes

of secondary hypertension.


CLASS

MOA

NAMES

Indications

Adverse Effects

Loop Diuretic

(-ide)

Thiazide Diuretics

Sulfonamide loop diuretic. Inhibits co-transport

system (Na+, K+, 2 CJ-) of thick ascending

limb of loop of Henle.

Stimulates PGE release (vasodilatory effect

on afferent arteriole)
Thiazide diuretic. Inhibits NaCl reabsorption in

early distal tubule, reducing diluting capacity

of the nephron (weak diuretic); increases Ca2+ excretion.


Lasix (Furosemide)( 20, 40 mg)

Ethacrynic acid (25-50 mg) (used in case of Sulfa Allergy.


Hydrochlorothiazide (12.5, 25, 50 mg)



Edematous states (CHF, cirrhosis, nephrotic

syndrome, pulmonary edema), hypertension,

hypercalcemia.


Ototoxicity, Hypokalemia, Dehydration, Allergy

(sulfa), Nephritis (interstitial), Gout.



ACE-Inhibitor

(-pril)

inhibit angiotensin-converting enzyme thereby decreasing angiotensin II, a potent vasoconstrictor.

Lisinopril ( 10, 20, 40 mg)

Enalapril

Captopril

Ramipril



Use in diabetic to prevent kidney damage; Hypertension, CHF, Prevent unfavorable heart remodeling

as a result of chronic hypertension and IHD



Avoid in bilateral renal artery stenosis.

Cough, Angioedema, Teratogen (fetal renal agenesis),decreases creatinine clearance (GFR)

Hyperkalemia, and Hypotension


ARB

(-sartan)

Blocks binding of angiotensin to a receptor

Losartan (12.5mg, 25mg, 50mg, 100mg)

Valsartan ( 20 mg, 40 mg, 80 mg)

Candesartan ( 4 mg, 8 mg, 16 mg, 32 mg)



Angiotensin II receptor have

effects similar to ACE inhibitors but do not increase bradykinin, therefore there is no cough or angioedema.






Beta Blocker

(-lol)

Decrease heart rate and contractility by blocking b- adrenergic receptors thereby decreasing the CO; decrease renin secretion (clue to

b1-receptor blockade on JGA cells)



Atenolol (25 mg, 50 mg, 100 mg)

Metoprolol (25 mg, 50 mg, 100 mg)

Propranolol ( 10 mg, 20 mg, 40 mg, 80 mg)


Atenolol, Carvedilol and Metoprolol decrease mortality in CHF; 1st line for Rx of angina and MI; class II antiarrythmic with negative chromotropic effect, used in SVT

Impotence, exacerbation of asthma,

cardiovascular adverse effects (bradycardia, AV

block, CHF), CNS adverse effects (seizures,

sedation, sleep alterations); use with caution in

diabetics


Calcium Channel Blockers

Block voltage-dependent L-type calcium channel s of cardiac and smooth muscle and thereby

reduce muscle contractility.



Amlodipine ( 2.5 mg, 5 mg, 10 mg)

Diltiazem ( 30 mg) Verapamil ( 120 mg, 180 mg, 240 mg)



Heart-verapamil > diltiazem > amlodipine = nifedipine (verapam il = ventricle) .Vascular smooth muscle -amlodipine = nifedipine > diltiazem > verapamil.

Cardiac depression, AV block, peripheral edema, flushing, dizziness, and constipation.

Alpha Blockers

Central

Vasodilation through alpha blockade.

Blocks alpha receptors at the bladder neck promoting bladder emptying.



Prazosin,( 1mg, 2 mg, 5 mg, 10 mg)

Terazosin ,( 1mg, 2 mg, 5 mg, 10 mg) ,

Doxazosin ( 1mg, 2 mg, 4 mg, 8 mg)

Tamsulosin ( 0.4 mg, 0.8 mg, 1.2 mg)



Used for HTN with BPH.

1st-close orthostatic hypotension, dizziness,

headache


Sedation, t serum cholesterol

Vasodilators

Smooth muscle relaxation via guanylyl cyclase pathways, Vasodilates arterioles > veins, and decreases afterload.

Hydralazine ( 25 mg, 50 mg, 100 mg)

First-line therapy for hypertension in pregnancy.

Severe hypertension, CHF



Compensatory tachycardia (contra indicated in angina/CAD ),( co administered with b blocker) , fluid retention, headache,

angina. Lupus-like syndrome.




Indications for Specific Medications:


Coronary artery disease

Beta blocker

Congestive heart failure

Beta blocker, ACE, or ARB

Migraine

Beta blocker, CCB

Hyperthyroidism

Beta blocker

Osteoporosis

Thiazide

Depression

No beta blockers

Asthma

No beta blockers

Pregnancy

Alpha methyldopa, Hydralazine

BPH

Alpha blockers

Diabetes

ACE/ARB

African American

CCB

JNC 8 Summary of Recommendations:

  1. In the general population aged ≥60 years, initiate pharmacologic treatment to lower blood pressure (BP) at systolic blood pressure (SBP) ≥150 mm Hg or diastolic blood pressure (DBP) ≥90 mm Hg and treat to a goal SBP <150 mm Hg and goal DBP <90 mm Hg.

  2. In the general population <60 years, initiate pharmacologic treatment to lower BP at DBP ≥90 mm Hg and treat to a goal DBP <90 mm Hg.

  3. In the general population <60 years, initiate pharmacologic treatment to lower BP at SBP ≥140 mm Hg and treat to a goal SBP <140 mm Hg.

  4. In the population aged ≥18 years with chronic kidney disease (CKD), initiate pharmacologic treatment to lower BP at SBP ≥140 mm Hg or DBP ≥90 mm Hg and treat to goal SBP <140 mm Hg and goal DBP <90 mm Hg.

  5. In the population aged ≥18 years with diabetes, initiate pharmacologic treatment to lower BP at SBP ≥140 mm Hg or DBP ≥90 mm Hg and treat to a goal SBP <140 mm Hg and goal DBP <90 mm Hg.

  6. In the general nonblack population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB).

  7. In the general black population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic or CCB.

  8. In the population aged ≥18 years with CKD, initial (or add-on) antihypertensive treatment should include an ACEI or ARB to improve kidney outcomes. This applies to all CKD patients with hypertension regardless of race or diabetes status.

  9. The main objective of hypertension treatment is to attain and maintain goal BP. If goal BP is not reached within a month of treatment, increase the dose of the initial drug or add a second drug from one of the classes in recommendation 6 (thiazide-type diuretic, CCB, ACEI, or ARB). The clinician should continue to assess BP and adjust the treatment regimen until goal BP is reached. If goal BP cannot be reached with 2 drugs, add and titrate a third drug from the list provided. Do not use an ACEI and an ARB together in the same patient. If goal BP cannot be reached using only the drugs in recommendation 6 because of a contraindication or the need to use more than 3 drugs to reach goal BP, antihypertensive drugs from other classes can be used. Referral to a hypertension specialist may be indicated for patients in whom goal BP cannot be attained using the above strategy or for the management of complicated patients for whom additional clinical consultation is needed.


Secondary Hypertension:

Investigate for secondary hypertension if you see the following:



  • Young(< 30) or old(> 60) patient

  • Failure to control pressure with 2 medications.

HTN Urgency:

≥180/120 mmHg without evidence of end organ damage


HTN Emergency:

≥180/120 mmHg with symptoms or evidence of end organ damage (papilledema, chest pain, acute kidney injury, encephalopathy, focal neurological deficit). These patients should be immediately sent to the ER


BOARD PEARLS:

  • # Drug of choice for hyertensive emergency in pregnancy - hydrazine (S/E : coronary steel syndrome)




  • # Eplerenone is a pottasium sparing diuretic but it does not cause gynecomastia.




  • # 1st choice of drugs in African American with HTN – CCB(amlodipine)




  • # ACE inhibitors and ARB’s are C/I in pregnant woman.




  • # Drug of choice for patients with HTN with asthma- amlodipine




  • # Drug of choice patients HTN with COPD/angina/supraventricular tachycardia with angina - verapamil.




  • # Hydrochlorothiazide increases calcium and parathyroid hormone.

#S/E of ACE Inhibitors mnemonic: CAPTOPRIL.

C : Cough

A : Angioedema

P : prodrug(All ACE inhibitors are prodrugs except Captopril and lisinopril)

T : taste alterans(Dysguesea)

O: Orthostatic hypotension.

P : Pregnancy C/I

R : Renal stenosis C/I

I : Increase potassium

L : Lowers angiotensin II production.



  • # Drug of choice for HTN with BPH – Tamsulosin. It does not cause orthostatic hypotention.







  • # Causes of secondary HTN mnemonic (CHAPS)

C: Cushings syndrome

H : Hyperaldosteronism(CONN’s Syndrome)

A : Aortic coarctation

P : Pheochromocytoma

S : Stenosis of renal arteries.

Clinical Vignettes


  1. A 45 Yo male presented for routine physical exam, he has no complaints, his Vital signs are as follows: BP 155/90 , HR: 60, Temp: 98, Resp: 13

Which of the following is the best next step in management?

a. Initiate Lisinopril

b. Initiate a diuretic

c. Repeat in 2 wks

d. Doppler U/S of the kidneys


  1. A 32 Y/O male presented for routine health care exam with mild weakness of lower extremities, polydipsia and polyuria, he denied any other complaints, his vital signs are BP: 135/95 , HR: 76, Temp 97.1 , Respiration: 12, His chemistry profile is as follows:

Na: 141


K: 2.8

Cl: 105


Ca: 9.5

Blood Glucose: 76


Which of the following is the best next step in management?

a. Repeat the BP measurement in 2 weeks

b. Initiate HCTZ

c. Measure Aldosterone/ Renin Ratio

d. Initiate lifestyle changes.
3.A 55 YO male with type 2 DM presented with HTN on more 3 readings, he was initiated on Lisinopril 10 mg 1 wk. ago, his GFR had been decreased from 90 ml/min at that time to 81 ml/min , which of the following is the best next step in management?


  1. Switch to Candesartan 4mg

  2. Switch to a diuretic

  3. Initiate Dialysis

  4. Continue treatment with Lisinopril

4. You are seeing a 45-year-old diabetic woman who reports bilateral

lower extremity peripheral edema. In addition to diabetes, she has hypertension

and depression. Which of the following medications is the likely

cause of her edema?


  1. Fluoxetine

  2. Metformin

  3. Glyburide

  4. Hydralazine

e. Hydrochlorothiazide

5. A 52 YO male patient with HTN presents for complete physical examination, he is taking Amlodipine 10 mg/d, he eats a well balance healthy diet and exercises regularly, but he complains of leg swelling in the last 3 months, physical examination confirms bilateral pitting edema, His cardiac exam is unrevealing, his EKG is normal and His vital signs : BP 130/82, HR: 88, Temp : 97.2 , Respiration: 12

His blood work is as follows:

Na: 140


K: 4.1

Cl: 104


CO2: 30

Anion Gap: 7

Glucose: 78

BUN: 20


Creatinine: 0.8

Ca: 9.1


Albumin: 4.3

Globulin: 2.9

ALP: 90

ALT: 30


AST: 35

Bilirubin total: 0.6

GFR: 110
Which of the following is the best explanation of these findings:


  1. Congestive Heart Failure

b. Drug side effects

c. Renal failure

d. Liver Injury

e. lymphatic obstruction

6 .A 58 YO male presented to the ER with acute chest pain, he was diagnosed with ST elevation myocardial infarction and was discharged 10 days later on medications.

Two years later he was found dead in his apartment without obvious reason.

The autopsy showed dilated ventricular chambers of the heart with increased cardiac diameters. Which of the following would prevent the subsequent complication if given before?


  1. Atenolol 100 mg

  2. Aspirin 81 mg

  3. Captopril 50 mg

  4. HCTZ 12.5 mg

  5. Simvastatin 20 mg

7. A 1hr neonate born to a 33 YO female presented with respiratory distress immediately after birth, examination revealed a flattened nose, recessed chin, prominent epicanthal folds, and low-set abnormal ears, his mother has oligohydramnios during her pregnancy, which of the following scenario is likely during the pregnancy?




  1. Diabetes treated with metformin

  2. HTN treated with alpha methyl dopa.

  3. DVT treated with Coumadin

  4. Infection treated with tetracycline.

  5. HTN treated with Lisinopril.

8. You have diagnosed a 35-year-old African American man with hypertension.

Lifestyle modifications helped reduce his blood pressure, but he was

still above goal. You chose to start hydrochlorothiazide, 25 mg daily. This

helped his blood pressure, but it is still 142/94 mm Hg. Which of the following

is the best approach to take in this situation?

a. Increase his hydrochlorothiazide to 50 mg/d

b. Change to a loop diuretic

c. Change to an ACE inhibitor

d. Change to a β-blocker

e. Add an ACE inhibitor.
9.A 58 YO male presented to the ER with headache and confusion for 3 hr, his past medical history is significant for HTN, his vital signs : BP 118/110, HR: 90, Temp 98, Respiration: 12, physical exams shows increased DTRs, which of the following is the best treatment ?


  1. Sublingual Nifedipine

  2. IV labetalol

  3. Oral Atenolol

  4. IV furosemide.

10. You are caring for a 45-year-old man with hypertension, gastroesophageal

reflux, and depression. His medication list includes hydrochlorothiazide,

verapamil, atenolol, omeprazole, and bupropion. He is

complaining of difficulty with ejaculation. Which of the following medications

is the most likely cause of this problem?

a. Hydrochlorothiazide

b. Verapamil

c. Atenolol

d. Omeprazole

e. Fluoxetine

11. A 47-year-old man with a history of hypertension presents to the ED

complaining of continuous left-sided chest pain that began while snorting

cocaine 1 hour ago. The patient states he never experienced chest pain in

the past when using cocaine. His BP is 170/90 mm Hg, HR is 101 beats per

minute, RR is 18 breaths per minute, and oxygen saturation is 98% on

room air. The patient states that the only medication he takes is alprazolam

to “calm his nerves.” Which of the following medications is contraindicated

in this patient?

a. Metoprolol

b. Diltiazem

c. Aspirin

d. Lorazepam

e. Nitroglycerin


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