Week 2 discussion.
Apply information from the Aquifer virtual case studies to answer the following questions:
- What is the Chief complain in the case studies? What are important questions to ask the patients to formulate the history of present illness and what did the patients tell you?
- What components of the physical exams are important to review in the cases? What are pertinent positive and negative physical exam findings to help you formulate your diagnosis?
- Which differential diagnosis is to be considered with each case study? What was your final diagnosis?
Answer the same questions for case study 1 and 2
Provide references
Do 2 pages.
South University College of Nursing and Public Health Graduate Online
Nursing Program
Aquifer Internal Medicine
Internal
Medicine
15: 50-
year-old
male with
cough and
nasal
congestion
Author/Editor:Author/Editor: Jennifer Bierman, MD
INTRODUCTION HISTORY
You speak with Dr. Griffin about Mr. Taleb.You speak with Dr. Griffin about Mr. Taleb.
!
https://southu-nur.meduapp.com/
https://southu-nur.meduapp.com/document_sets/6094
It is September and you are working with Dr. Erin Griffin in her outpatient
general medicine clinic. She asks you to see Mr. Fadil Taleb, a 50-year-old male
with respiratory symptoms. Dr. Griffin tells you he is relatively new to the
practice and has been seen only once in the past for a general physical.
HISTORY HISTORY
You begin to take a history from Mr. Taleb.You begin to take a history from Mr. Taleb.
!
You enter the room and introduce yourself. You then begin taking a history.
“What brings you to the oGce today”What brings you to the oGce today?”
“I have been sick for the past three or four days. It started with my throat
being scratchy and lots of sneezing. Now my nose is all stopped up, and
I’m blowing it constantly. I’m also coughing a lot.”
“Have you had a fever?””Have you had a fever?”
“I felt warm the first day but now I just have the chills occasionally. I am
also really tired.”
The best options are indicated below. Your selections are indicated by
the shaded boxes.
“Is anyone else you know ill?””Is anyone else you know ill?”
“My kids were sick at the end of last week. One of them is still coughing
but the others seem better. My kids are in school right now, and during
the school year it seems like one of them picks up something at school
almost every other week. I ride the bus to and from work, and there are
always people coughing there.”
“Do you smoke?””Do you smoke?”
“Yeah, doc, I know it’s not good for my health, but I do smoke. Usually it’s
about a half pack per day, but since I have been sick, I have been smoking
only one or two cigarettes a day.”
Question
What risk factors does the patient have for an upper respiratory
infection (URI)? Select all that
apply.
A. Exposure to sick contacts, especially children in the
home
B. Cigarette smoking
C. Season
SUBMITSUBMIT
Answer Comment
> The correct answers are A, B, C> The correct answers are A, B, C
Risk Factors for Upper Respiratory Infection
Adults with children in their homesAdults with children in their homes have more frequent URIs
(colds). American adults average two to four colds per year while
children average six to eight. Crowded conditions predispose
TEACHING POINTTEACHING POINT
patients to infection; thus, the incidence of colds is higher in those
who spend time in schools.
Studies have shown that cigarette smokecigarette smoke causes structural
changes in the respiratory tract and diminishes the immune
response to both bacterial and viral respiratory infections. Also,
smokers have more severe symptoms when they have an URI.
There is a seasonal incidence of viral URIseasonal incidence of viral URI correlating with
colder months in temperate areas. They begin in early fall and
continue through the spring. Humidity probably plays a role with
virus survival.
References
Archavi L, Benowitz NL. Cigarette Smoking and Infection. Arch Intern Med. 2004;164:2206-2216.
Gwaltney JM. “The Common Cold.” Principles and Practices of Infectious Diseases. 6th ed. St.
Louis, MO: Churchill Livingston; 2005.
ROS AND CHART REVIEW HISTORY
You continue your history with Mr. Taleb.You continue your history with Mr. Taleb.
!
“Tell me more about your cough. Do you bring anything up?”
“No, it’s a dry cough, but it wakes me up at night several times.”
“Do you feel short of breath?”
“No, not really.”
“Does your chest hurt?”
“No. Can’t say that it does.”
“Have you tried any medicine to help?”
“My face has felt full, so I took some Actifed Cold and Allergy tablets, but
they didn’t seem to do much. I’ve also taken some Cold-EEZE, vitamin C,
and Waltussin DM, but nothing is helping.”
“Have you had problems like this before?”
“I had this same thing last fall and it lasted a couple of weeks. I hate to
bother you doctors with this, but I don’t want to get any worse.”
You review Mr. Taleb’s chart and confirm the following:
Past Medical History:Past Medical History:
Hyperlipidemia (6 months ago)
Lab Values:Lab Values: Conventional:Conventional: SI:SI:
Total cholesterol 220 mg/dL 5.70 mmol/L
HDL 41 mg/dL 1.06 mmol/L
LDL 145 mg/dL 3.76 mmol/L
Medications:Medications:
None except over-the-counter medications
Actifed Cold and Allergy (phenylephrine and chlorpheniramine)
Cold-EEZE (zinc gluconate)
Vitamin C
Waltussin DM (guaifenesin and dextromethorphan).
AllergiesAllergies:
None
Family History:Family History:
Mother: Alive and well.
Father: High cholesterol, HTN.
Paternal uncle: Coronary artery disease, hx of MI.
Three sisters: Well.
Social History:Social History:
Married and monogamous. Works as a computer specialist for the help desk at
the hospital. Three children ages 12, 15, and 18 years old. Has smoked half
pack per day for the past 25 years. Quit with each of his wife’s pregnancies,
then resumed a year or so later. He rarely drinks alcohol and has never used IV
drugs.
Review of Systems:Review of Systems:
No headache, myalgias, hemoptysis, weight loss, or night sweats.
See the associated reference ranges in conventional and SI units.
SUMMARY STATEMENT CLINICAL REASONING
Question
Based on what you know about the patient so far, write a one- to
three- sentence summary statement to communicate your
understanding of the patient to other providers.
Guidel ines for summary statements.Guidel ines for summary statements.
https://www.meduapp.com/resources/laboratory_reference_values
Your response is recorded in your student case report.
Letter Count: 0/1000
SUBMITSUBMIT
Answer Comment
Mr. Taleb is a 50-year-old male with a history of tobacco use who has
a several day history of sore throat, nasal congestion, and non-
productive cough which awakens him at night. He denies chest pain,
myalgias, hemoptysis, weight loss or dyspnea.
The ideal summary statement concisely highlights the most pertinent
features without omitting any significant points. The summary
statement above includes:
1. Epidemiology and risk factors: 50-year-old male with a history
of tobacco use.
2. Key clinical findings about the present illness using qualifying
adjectives and transformative language:
rhinitis
sore throat
non-productive cough present at night
lack of chest pain, myalgias, weight loss, hemoptysis or dyspnea.
The best options are indicated below. Your selections are indicated by
the shaded boxes.
DIFFERENTIAL DIAGNOSIS 1 CLINICAL REASONING
Question
Based on Mr. Taleb’s history, which of the following are the top threethree
diagnoses on your differential? Select all that apply.
A. Allergic rhinitis
B. Acute bacterial sinusitis
C. Acute bronchitis
D. Asthma
E. Bacterial pneumonia
F. Influenza
G. Strep pharyngitis
H. Tuberculosis
I. Viral upper respiratory infection
J. Infectious mononucleosis
K. Pertussis
SUBMITSUBMIT
Answer Comment
> The correct answers are A, C, I> The correct answers are A, C, I
Most Likely / Important DiagnosesMost Likely / Important Diagnoses
The following are the most likely / important diagnoses at this point:
allergic rhinitis (A)allergic rhinitis (A)
acute bronchitis (C)acute bronchitis (C)
viral upper respiratory infection (URI) (I)viral upper respiratory infection (URI) (I)
DiUerential of Acute Respiratory Symptoms in Middle-
Aged Male with Tobacco History
The following diagnoses are less likely:The following diagnoses are less likely:
Acute bacterial sinusitisAcute bacterial sinusitis
Occurs when an initial viral nasopharyngeal infection spreads to
become a secondary bacterial infection of the paranasal sinuses.
Viral rhinosinusitis is diagnosed when symptoms or signs of
acute rhinosinusitis (nasal congestion, facial pain/pressure,
purulent nasal discharge) are present less than 10 days, and the
symptoms are not worsening.
Acute bacterial rhinosinusitis (ABRS) should be diagnosed when
symptoms or signs of acute rhinosinusitis fail to improve within 10
days or when symptoms or signs worsen within 10 days after an
initial improvement (double worsening).
AsthmaAsthma
Often presents with a chronic, nocturnal cough — or cough,
dyspnea, and/or wheezing associated with exertion.
Symptoms do not include rhinorrhea, sore throat, sneezing, and
chills — these are suggestive of an infectious etiology rather than
asthma.
Bacterial pneumoniaBacterial pneumonia
Characterized by persistent fever, cough with purulent sputum,
dyspnea, and often pleuritic chest pain.
Require symptoms present long enough to suggest a secondary
bacterial infection such as pneumonia.
InfluenzaInfluenza
Characterized by upper and lower respiratory tract symptoms
accompanied by systemic symptoms. High fever of 102 to 104 F
and chills are very common, along with severe myalgias and
headache.
Stuffy and runny nose can be present in influenza, but are more
TEACHING POINTTEACHING POINT
characteristic of the common cold.
Onset is so abrupt that patients can often identify the precise
time their symptoms began. Outbreaks typically occur during
winter months.
Streptococcal pharyngitisStreptococcal pharyngitis
Typically presents with abrupt onset of sore throat, painful
swallowing, and fever. Cough, nasal congestion, and rhinorrhea
coryza are uncharacteristic.
TuberculosisTuberculosis
Chronic illness with weight loss, night sweats, or hemoptysis.
Inquiry about travel to developing countries, exposure to TB, and
HIV risk factors would be indicated if TB was a serious
consideration.
Infectious mononucleosisInfectious mononucleosis
Characterized by sore throat, fatigue, and lymphadenopathy.
Cough is not a typical feature.
Pertussis (whooping cough)Pertussis (whooping cough)
Had been uncommon in the U.S. due to near universal
vaccination. However, in the past few years the incidence has
increased, and outbreaks in schools have occurred in many states.
This is likely due to decreasing use of vaccination, waning immunity
in those previously vaccinated, or just better testing and reporting.
The Centers for Disease Control (CDC) recommends that all
adults receive a one-time booster, which is accomplished with a
Tdap vaccine. Adolescents are also receiving an additional booster.
Pertussis has three phases:
1. catarrhal – seven to ten days of symptoms indistinguishable
from a URI, with rhinorrhea, malaise, low-grade fever, and mild
cough
2. paroxysmal – one to six weeks of paroxysms of rapid
coughing associated with a high-pitched whoop that is frequent
and often worse at night; this whoop is not common in adults
3. convalescent – one to three weeks of lessening cough
http://www.cdc.gov/vaccines/vpd-vac/pertussis/recs-summary.htm
The catarrhal phase is unlikely without a known exposure.
References
Fauci A, Braunwald E, Kasper D, et al. Harrison’s Principles of Internal Medicine, Part Eight.
Disorders of the Respiratory System. New York, NY: McGraw-Hill Inc.; 2008.
Rosenfeld RM, Piccirillo JF, Chandrasehkar, SS, et al. Clinical Practice Guideline: Adult Sinusitis.
Otolaryngol Head Neck Surg. April 2015; 152(S2):s1-s39
DIFFERENTIAL DIAGNOSIS 2 CLINICAL REASONING
At this point, URIURI, allergic rhinitisallergic rhinitis, and acute bronchitisacute bronchitis seem to be the
most likely diagnoses. You are anxious to gather more information from Mr.
Taleb.
DiUerential of Acute Respiratory Symptoms in Middle-Aged
Male with Smoking History
Viral URI
Viral URI
Sore throatSore throat is often the first symptom.
SneezingSneezing and stuffy nosestuffy nose are classic symptoms,
particularly in its first stage.
AllergicAllergic
rhinitisrhinitis
The cardinal symptom is the seasonal occurrenceseasonal occurrence
of sneezing, watery rhinorrhea, nasalof sneezing, watery rhinorrhea, nasal
congestion, and itchy, watery eyescongestion, and itchy, watery eyes.
Causes symptoms that last for weekslast for weeks during
exposure to environmental allergens; thus, a short
duration of symptoms would argue against this
diagnosis.
Fever is not common, and if present argues against
this diagnosis.
A self-limited inflammation of the large airways in
the lung which is characterized by coughcough. It leads to
excessive tracheobronchial mucus production
TEACHING POINTTEACHING POINT
AcuteAcute
bronchitisbronchitis
sufficient to cause purulent sputumpurulent sputum in half of
patients. The cause is usually viral, but it can leadbut it can lead
to a secondary bacterial infection.to a secondary bacterial infection.
Symptoms during the first few days are hard to
distinguish from those of a URI. However, the cough
of acute bronchitis persists for more than fivepersists for more than five
daysdays.
PHYSICAL EXAM PHYSICAL EXAM
You listen to Mr. Taleb’s breath sounds.You listen to Mr. Taleb’s breath sounds.
!
You proceed with the physical examination. During your examination, you note
the following:
Vital signs:Vital signs:
Temperature:Temperature: 37.2 C (98.9 F)
Pulse:Pulse: 76 beats/minute
Respiratory rate:Respiratory rate: 14 breaths/minute
Blood pressure:Blood pressure: 125/76 mmHg
Weight:Weight: 91 kg (200 lbs)
Height:Height: 178 cm (70 in)
Body Mass Index:Body Mass Index: 28.7 kg/m2
General:General: Well developed, well nourished male. No acute distress.
Eyes:Eyes: Clear conjunctiva, no discharge, anicteric sclera.
Ears:Ears: Canals are clear. TMs are clear. No redness or bulging.
Nose:Nose: No maxillary or frontal sinus tenderness on palpation. No dullness on
transillumination.
Throat:Throat: Slightly reddened posterior pharynx but no exudates or tonsillar
enlargement. There is no cobblestoning.
Neck:Neck: No cervical or supraclavicular lymphadenopathy.
Chest:Chest: Good excursion. No dullness to percussion. Rhonchi throughout all lung
fields. There are no wheezes or crackles.
CV:CV: RRR normal S1 and S2. No murmurs, rubs, or gallops.
Skin:Skin: Yellow nicotine stains on right ring and middle finger.
Acute Respiratory Physical Exam Findings
CobblestoningCobblestoning
Postnasal drip is manifested by symptoms of the sensation of dripping down
the back of the throat and frequent throat clearing. On examination you may
see a reddened pharynx, discharge, and sometimes a “cobblestone road”
appearance of the posterior pharynx. This is due to swollen lymphoid tissue.
RhonchiRhonchi
Low-pitched, continuous sounds often described as similar to a snoring
sound. Generated by narrowing of larger airways due to mucus from
bronchitis or narrowing from asthma or COPD.
WheezesWheezes
High-pitched whistling sound during breathing when air flows through a
TEACHING POINTTEACHING POINT
The best option is indicated below. Your selections are indicated by
the shaded boxes.
narrowed airway, most commonly heard in asthmatics and patients with
acute bronchospasm.
CracklesCrackles
Synonymous with rales. A discontinuous sound heard more often during
inhalation caused by airway opening. The sounds are often divided into dry
or moist, with the dryness being caused by disease processes such as
fibrosis and the moistness or wetness being secondary to heart failure or
pneumonia.
Question
Based on your clinical suspicion, which one physical exam maneuver
would be most helpful to further evaluate the current findings?
Choose the single best answer.
A. Feel for vibrations along the posterior chest while
patient is saying ninety-nine.
B. Auscultate while patient is saying eeeee.
C. Ask the patient to cough and repeat the auscultation.
D. Listen at bases while patient in the lateral decubitus
position.
SUBMITSUBMIT
Answer Comment
> The correct answer is C> The correct answer is C
Acute Respiratory Physical Exam Findings
Asking the patient to cough and repeat the examinationAsking the patient to cough and repeat the examination
should decrease or eliminate rhonchi if they are caused by
secretions.
TEACHING POINTTEACHING POINT
Feeling for vibrations along the posterior chest while the patient is
saying “ninety-nine” is an example of testing for tactile fremitustactile fremitus.
Tactile fremitus is increased over areas of consolidation (as in lobar
pneumonia) and decreased over a pneumothorax. Increased
fremitus in a consolidated lung occurs because sound waves travel
faster through liquid (the consolidation) than through air.
Decreased fremitus occurs in the setting of a pneumothorax
because the air is a barrier to the sound waves.
Auscultating while the patient says “eeee” (like the letter E) is an
example of egophonyegophony. If lung consolidation is present, the high-
frequency noises are preferentially transmitted across the
abnormal lung tissue, causing the observer to hear an “aaaa” (like
the letter A) through the chest. This is also known as “e to a
changes.”
Listening to the bases while the patient is in a lateral decubitus
position could potentially identify pleural effusions, but this
procedure has low sensitivity and specificity and is not a common
physical exam maneuver.
PHYSICAL EXAM QUESTION TEACHING
” DEEP DIVEDEEP DIVE
The best option is indicated below. Your selections are indicated by
the shaded boxes.
You perform a nasal exam on Mr. Taleb.You perform a nasal exam on Mr. Taleb.
!
Dr. Griffin joins you to review what you have covered with Mr. Taleb up to this
point. She asks what you found on the nasal examination. You confess you
didn’t look up his nose, but will now.
You examine Mr. Taleb’s nose and find clear discharge with slight erythema of
the nasal mucosa.
Question
Which findings on a nasal examination are most consistent with
bacterial sinusitis? Choose the single best answer.
A. Mucosal edema, erythema, and purulent nasal
discharge.
B. Mild mucosal edema that is shiny or glassy-appearing,
and clear
nasal discharge.
C. Mild mucosal edema that is pale or bluish in color. Clear
nasal discharge.
SUBMITSUBMIT
Answer Comment
> The correct answer is A> The correct answer is A
Nasal Examination Findings and Associated Conditions
Purulent discharge in addition to mucosal edema
and erythema
Bacterial
sinusitis
Mucosa is either normal or mildly edematous and
shiny or glassy-appearing, clear nasal discharge
Viral URI
Mild mucosal edema that is boggy and pale or
bluish in color as well as clear nasal discharge
Allergic
rhinitis
Remember that not all that is green is bacterial. When a patient
describes yellow-green discharge, this may be caused by either a
virus or bacteria.
RESPIRATORY PATHOGENS TEACHING
TEACHING POINTTEACHING POINT
The best options are indicated below. Your selections are indicated by
the shaded boxes.
Dr. Griffin asks you about treatment.Dr. Griffin asks you about treatment.
!
You tell Dr. Griffin, “I think Mr. Taleb has a viral upper respiratory infection. He
does not have a fever, productive cough, or signs of consolidation – ruling out
pneumonia. His throat is not very red, and there are no exudates, so I don’t
think it is strep throat. Since he does not have purulent nasal discharge, sinus
tenderness or tooth pain, sinus infection is unlikely. His rhonchi support the
possibility of early viral bronchitis, but it is too early in his illness to say for sure.
Given the constellation of nasal congestion, scratchy throat, and cough with a
benign physical, I think a viral URI is the most likely diagnosis.”
Dr. Griffin says, “I agree with you that Mr. Taleb is suffering from the common
cold. How do you think we should treat him?”
At this point, Mr. Taleb interjects, “A Z-Pack has worked for me in the past.”
Question
Before answering, you need to consider possible pathogens. What are
the most common pathogens for the common cold? Select all that
apply.
A. Streptococcus pneumoniae
B. Influenza
C. Rhinovirus
D. Corona viruses
E. Mycoplasma pneumoniae
F. RSV
G. Metapneumovirus
SUBMITSUBMIT
Answer Comment
> The correct answers are B, C, D, F, G> The correct answers are B, C, D, F, G
Pathogens for Pneumonia
Streptococcus pneumoniae is a gram positive diplococcus, which is
a major worldwide cause of pneumonia. It also causes many types
of infection other than pneumonia, including acute sinusitis, otitis
media, meningitis, osteomyelitis, septic arthritis, and endocarditis.
It does not cause upper respiratory symptoms like coryza.
Mycoplasma pneumoniae is another common cause of community
acquired pneumonia; although it can cause a mild sore throat,
nasal congestion and rhinorrhea are not characteristic. It often has
a gradual onset and can last several weeks.
Most Common Pathogens for the Common Cold
The common cold is caused by a multitude of viruses, with
Rhinovirus causing up to 50% of colds in adults.
VirusVirus
Percentage of URI’sPercentage of URI’s
caused by this viruscaused by this virus
TEACHING POINTTEACHING POINT
TEACHING POINTTEACHING POINT
Rhinovirus 30-50%
Corona viruses 10-15%
Parainfluenza virus 5%
Respiratory syncytial virus (RSV) 5%
Influenza virus 25-30%
Adenoviruses 5-10%
Others: enteroviruses, human
metapneumovirus
< 1%
References
Gwaltney JM. “The Common Cold.” Principles and Practices of Infectious Diseases. 6th ed. (St.
Louis, MO: Churchill Livingston, 2005).
TREATING THE URI THERAPEUTICS
With some help from Dr. Griffin, you explain to Mr. Taleb that you believe he
has a common cold. You go on to explain that colds are caused by viruses and
not bacteria and that antibiotics treat bacterial infections only. You end by
telling him that viral infections are self-limited, and treatment is supportive. You
discuss how to prevent spreading the cold and and inform Mr. Taleb when he
can expect to feel better. You then ask if he has any questions.
“Are you sure it is not the Zu? Should I get a Zu shot?””Are you sure it is not the Zu? Should I get a Zu shot?”
“My last doctor always gave me antibiotics. Are you sure I don’t”My last doctor always gave me antibiotics. Are you sure I don’t
need them?”need them?”
You give Mr. Taleb a patient handout about colds and antibioticspatient handout about colds and antibiotics that he
https://medu-relier-production.s3.amazonaws.com/files/SIMPLE-15-L88Ivus0W10OTuQ7C-OwCXFwGC3gvz8HVACiGr7oX4HdBMarLwp/compressed/images/252153
The best options are indicated below. Your selections are indicated by
the shaded boxes.
can look over at home.
URI Prevention and Duration
PreventionPrevention
Respiratory viruses are spread from person to person by droplets from
coughing or sneezing. Prevent spreading the cold by frequent hand-washing
and using a tissue to block sneezes or coughs.
DurationDuration
Most commonly cold symptoms last seven to ten days, however 25% can last
up to two weeks. In smokers, the symptoms can be more severe and can last
longer.
Question
What are the best initial options to treat acute bacterial sinusitis?
Select all that apply.
A. Cefuroxime
B. Amoxicillin
C. Azithromycin
D. Trimethoprim-sulfamethoxazole
E. Amoxicillin-clavulanic acid
F. Doxycycline
G. No antibiotics
SUBMITSUBMIT
Answer Comment
TEACHING POINTTEACHING POINT
> The correct answers are E, F, G> The correct answers are E, F, G
Treatment of Acute Bacterial Sinusitis
Although Streptococcus pneumoniae and Haemophilus influenzae
are the most common organisms in bacterial sinusitis and can be
treated with antibiotics, avoiding antibiotics is indeed an option.
Many cases resolve on their own and a recent study showed that
antibiotics may not shorten the duration of acute bacterial
sinusitis.
If antibiotics are prescribed, amoxicillin clavulanate is first line
given increased resistance of H. Influenzae and S. Pneumoniae to
amoxicillin alone. Doxycycline or respiratory quinolones
(levofloxacin and moxifloxacin) are suggested for patients who are
penicillin allergic.
For a discussion on treatment of acute bacterial sinusitis, see the
Infectious Disease Society of America guideline ( ).
Trimethroprim-sulfamethoxazole is no longer recommended given
high rates of H. Influenzae resistance to trimethoprim-
sulfamethoxazole.
Streptococcus pneumoniae has increasing resistance to
macrolides, such as azithromycin or erythromycin, so their use
should be minimized.
Treatment of Chronic Bacterial Sinusitis
Chronic sinusitis is defined as symptoms lasting longer than 12
weeks. Chronic sinusitis is often polymicrobial, with anaerobes in
addition to aerobes. Thus, broader-spectrum antibiotics, such as
cefuroxime, quinolones or amoxicillin-clavulanic acid, should be
employed with the duration of therapy for three to six weeks.
TEACHING POINTTEACHING POINT
TEACHING POINTTEACHING POINT
https://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/IDSA%20Clinical%20Practice%20Guideline%20for%20Acute%20Bacterial%20Rhinosinusitis%20in%20Children%20and%20Adults
The best option is indicated below. Your selections are indicated by
the shaded boxes.
References
Gonzales R, Steiner JF, Sande MA. Antibiotic Prescribing for Adults with Colds, Upper Respiratory
Tract Infections, and Bronchitis by Ambulatory Care Physicians. JAMA. 1997; 278(11): 901-4.
Cantrell R, Young AF, Martin BC. Antibiotic Prescribing in Ambulatory Care Settings for Adults with
Colds, Upper Respiratory Tract Infections and Bronchitis. Clinical Therapeutics. 2002;24(1):170-82.
Louie JP, Bell LM. Appropriate Use of Antibiotics for Common Infections in an Era of Increasing
Resistance. Emergency Medicine Clinics of North America. 2002; 20(1): 69-91.
Shehab N, Patel PR, Srinivasan A, Budnitz. Emergency Department Visits for Antibiotic-Associated
Adverse Events. Clinical Infectious Diseases. 2008; 47:735-43.
Garbutt JA, Banister C, Spitznagel E et al. Amoxicillin for Acute Rhinosinusitis A Randomized
Controlled Trial. JAMA. 2012;307(7):685-692.
Williamson IG, Rumsby S, Benge S et al. Antibiotics and topical nasal steroid for treatment of acute
maxillary sinusitis. JAMA. 2007;298(21):2487-97
Chow AW, et al. Infectious Disease Society of America. IDSA clinical practice guideline for acute
bacterial rhinosinusitis in children and adults. Clin Infect Dis 2012 Apr;54(8):e72-e112
DIAGNOSTIC TESTING TESTING
You are about to discuss treatment options with Mr. Taleb when he asks,
“Should any other tests be done? My daughter had a throat swab when she got
sick. Since I smoke, do I need an x-ray to make sure I don’t have cancer?”
Question
What diagnostic tests should be done? Choose the single best answer.
A.
Chest x-ray
B. Rapid strep test
C. Throat culture
D.
Sinus CT
” DEEP DIVEDEEP DIVE
E. CBC with differential
F. Monospot or heterophile antibody
G. None
SUBMITSUBMIT
Answer Comment
> The correct answer is G> The correct answer is G
With Mr. Taleb’s clinical picture, no further studies areWith Mr. Taleb’s clinical picture, no further studies are
necessary at this time (G).necessary at this time (G).
Diagnostic Workup of Viral URI
None of the following are appropriate in the diagnosticNone of the following are appropriate in the diagnostic
workup of viral URI.workup of viral URI.
Chest x-ray
A chest x-ray is necessary to diagnose
pneumonia and would be a reasonable
test to perform if the lung exam showed
rales or signs of consolidation, or for an ill-
appearing patient with fever, tachypnea, or
hypoxemia. It is also indicated for patients
with chronic cough, i.e., a cough that has
lasted longer than six to eight weeks.
A chest x-ray is not routinely obtained in
smokers. The U.S. Preventive Services Task
Force (USPSTF) and The American Lung
Association both recommend lung cancer
screening with low dose CT scans (not
chest x-rays) for current or former
smokers 55 years or older with a 30 pack-
year smoking history.
Learn more about lung cancer screening
here:
1. NCBI article about lung cancer
mortality with low dose CT screening
TEACHING POINTTEACHING POINT
http://www.ncbi.nlm.nih.gov/pubmed/21714641
2. American Lung Association:
Guidance on CT lung cancer
Rapid strep
test
Rapid strep test is used clinically to detect
Group A Streptococcus, which causes
almost all bacterial pharyngitis. The newest
rapid antigen detection tests have good
sensitivity (80-90%) and specificity (95%).
However, most pharyngitis is viral, with
rhinoviruses being the most common.
The classic clinical picture of strep throat is
fever, sore throat, and absence of nasal
congestion or cough along with pharyngeal
erythema and exudates and tender
cervical adenopathy. A rapid strep test is
not necessary in the absence of these
symtpoms.
Throat
culture
Throat culture is the gold standard for
strep throat, but a result can take two to
three days.
Should not be performed without the
typical findings for streptococcal
pharyngitis.
Sinus CT
Radiological studies do not differentiate
bacterial sinusitis from viral sinusitis. More
than 80% of viral rhinosinusitis can have
abnormalities on CT or plain films. Thus, a
sinus CT is not a helpful test.
CBC with
differential
Results are typically normal in patients
with viral URIs, including sinusitis.
Although the white blood cell count can be
elevated in patients with influenza,
pneumonia, and bacterial pharyngitis, it
will not differentiate between them.
Results of a CBC won’t be available
immediately and won’t change
management. This test will only increase
the cost of care, not the quality.
http://www.lung.org/about-us/blog/2016/11/lung-cancer-screening-options.html
Monospot
or
heterophile
antibody
test
Monospot or heterophile antibody test is
done if infectious mononucleosis (IM) is
considered.
IM is rare in older adults, more common in
teens and young adults. The typical
symptoms include fever, sore throat, and
fatigue. Cervical lymphadenopathy is
usually prominent on physical
examination.
VIRAL VS. BACTERIAL PHARYNGITIS TESTING
You explain to Mr. Taleb why he does not need an x-ray or a throat swab.
Most pharyngitis is viral, with rhinoviruses being the most common etiology.
Only 5-15% of cases of pharyngitis are bacterial, with Group A streptococcus
causing almost all bacterial pharyngitis.
Although streptococcal pharyngitis is usually self-limited, treatment with
antibiotics is indicated to prevent acute rheumatic fever, reduce person-to-
person transmission, and decrease the incidence of local complications, such
as peritonsillar and retropharyngeal abscesses.
Post-streptococcal glomerulonephritis is an uncommon complication of strep
throat; there is no evidence that antibiotic treatment prevents it.
Decision Tools for Evaluation/Treatment of Strep Throat
Predictive rules have been developed that can be helpful in determining
which patients should undergo a rapid strep test. The most commonly used
of these rules, the Modified Centor Criteria, has a good negative predictive
value, but a relatively poor positive predictive value. Thus it is useful in
figuring out which patients likely do not have strep pharyngitis and therefore
do not need further testing. This test should not be used to make a diagnosis
TEACHING POINTTEACHING POINT
of strep pharyngitis in the absence of testing for strep.
Criteria: Modified CentorCriteria: Modified Centor (also called McIsaac Score)
Give one point for each positive response:
Tonsillar exudate or erythema
Anterior cervical adenopathy
Cough absent
Fever present:
Age 3 to 14 years: +1 point
Age 15 to 45 years: 0 points
Age over 45 years: -1 point
Standard practice has been to collect a rapid strep test in all children with a
Modified Centor score of 2 or more. Recently, the American College of
Physicians made a new recommendation for adults saying that rapid strep
testing should be reserved only for patients with a Modified Centor score of
3 or more. This reflects the lower prevalence of strep among adults with sore
throat, compared to children.
Approach: ClinicalApproach: Clinical
suspicion basedsuspicion based
on Modifiedon Modified
Centor scoringCentor scoring
Children Adults
Score of 3-5
Perform Rapid
Antigen Test
Perform Rapid Antigen Test
Score of 2
Perform Rapid
Antigen Test
Symptomatic treatment
without testing
… Rapid antigen test
Positive
Treat with
antibiotics
Treat with antibiotics
… Rapid antigen test
Negative
Perform
confirmatory
strep culture,
and treat if
positive
Symptomatic treatment
without further testing
(unless high risk such as
immunocompromised)
The best options are indicated below. Your selections are indicated by
Score of 0 or 1
Symptomatic
treatment
without testing
Symptomatic treatment
without testing
Antimicrobial therapy should be used only when Group A strep is highly likely.
Penicillin is the treatment of choice; erythromycin is an alternative when
patients are allergic to penicillin.
SYMPTOMATIC TREATMENT THERAPEUTICS
Mr. Taleb asks you what he can do to feel better.Mr. Taleb asks you what he can do to feel better.
!
Mr. Taleb smiles and says, “Ok, Doc. You’ve convinced me – I have a cold. If
antibiotics aren’t the answer, what can I do to get better?”
Question
Which of the following options work to decrease the frequency or
duration of symptoms? Select all that apply.
the shaded boxes.
A. Decongestants
B. Antihistamine combination therapy (with decongestant
and/or analgesic)
C. Antihistamines monotherapy
D. Mucolytics
E. Cough suppressants
F. Nonsteroidal anti-inflammatories
G. Vitamin C
H. Zinc
I. Echinacea
J. Ipratropium bromide nasal spray 0.06%
K. Oseltamivir
SUBMITSUBMIT
Answer Comment
> The correct answers are B, F, J> The correct answers are B, F, J
Upper Respiratory Infection Interventions
Interventions That Decrease the Frequency or Duration ofInterventions That Decrease the Frequency or Duration of
Symptoms of URISymptoms of URI
Non-selectiveNon-selective
antihistaminesantihistamines
Two moderate quality meta-analyses of
antihistamines monotherapy showed no
clinically significant reduction in severity or
duration of overall symptoms or nasal
obstruction and an increase in adverse
events, primarily sedation with first-
generation anti-histamines.
A 2015 Cochrane systematic review showed
TEACHING POINTTEACHING POINT
NSAIDsNSAIDs
that NSAIDs may improve most pain-related
symptoms caused by the common cold, but
there is no evidence that they improve the
cough, congestion, or rhinorrhea associated
with the common cold.
IpratropiumIpratropium
bromidebromide
One meta-analysis showed that use of
ipratropium bromide sprays three to four
times daily may decrease the symptoms of
rhinorrhea and sneezing, but not nasal
congestion.
AntihistamineAntihistamine
combinationcombination
therapy (withtherapy (with
decongestantdecongestant
and/orand/or
analgesic)analgesic)
Low-moderate quality meta-analysis
revealed the best evidence for
antihistamine-decongestant combination
(NNT = 5 for global symptoms); other
combinations had small to moderate
effects in adults and older children.
Interventions That Have Not Demonstrated Decrease inInterventions That Have Not Demonstrated Decrease in
Frequency or Duration of Symptoms of URIFrequency or Duration of Symptoms of URI
Despite the paucity of data, millions of dollars are spent on over-
the-counter (OTC) cold products each year.
Topical
decongestants
Topical decongestants are not recommended
for more than three days given the risk of
rhinitis medicamentosa (nasal congestion
caused by over-use of topical decongestants).
Oral decongestants are often prescribed.
There are no studies proving their efficacy,
although some studies show a small decrease
in nasal congestion and rhinorrhea.
Mucolytics
Mucolytics, such as guaifenesin, have not
been proven to improve symptoms.
Cough
suppressants
Cough suppressants, such as codeine and
dextromethorphan, are frequently prescribed
for cough suppression, though evidence of
efficacy from clinical trials is lacking.
Vitamin C
Studies have been mixed regarding the use of
large doses of vitamin C to either prevent or
treat the common cold.
Zinc
Echinacea
Although often touted in the lay press, several
controlled studies have shown that neither
zinc nor echinacea show benefit in the
treatment of cold symptoms.
Oseltamivir
(Tamiflu)
Oseltamivir (Tamiflu) is an oral agent used for
the prevention and treatment of influenza. If
given with the first 48 hours it can decrease
the duration of illness by two to three days. It
can also be used to prevent influenza in a
patient with a known exposure. However,
vaccination is the best way to preventvaccination is the best way to prevent
influenzainfluenza. Anyone who wants to reduce their
chances of getting the flu can be vaccinated,
but people who are at high risk of having
serious flu complications or people who live
with or care for those at high risk for
complications are given priority when vaccine
supplies are limited. Read more about who
should receive a flu vaccine at:
http://www.cdc.gov/FLU/protect/keyfacts.htm
FIVE A’S AND FIVE R’S MANAGEMENT
” DEEP DIVEDEEP DIVE
DIAGNOSES
MENUMENU
http://www.cdc.gov/FLU/protect/keyfacts.htm
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Dr. Griffin reviews the five A’s and five R’s of smoking cessation.Dr. Griffin reviews the five A’s and five R’s of smoking cessation.
!
You and Dr. Griffin step out of the room so Mr. Taleb can dress. Dr. Griffin says,
“I want to go over some information with you that is good to review before
discussing tobacco use with patients: the five A’s and five R’s for smoking
cessation.”
Tobacco Cessation Counseling
5 A’s – Help Tobacco Users Willing to Quit5 A’s – Help Tobacco Users Willing to Quit
AASK: at every visit. The initial step is to identify if the patient uses tobacco.
AADVISE: all tobacco users to quit. Emphasize the 5 R’s (relevance, risk,
rewards, roadblocks, and repetition).
AASSESS: willingness to quit. “Do you feel ready to stop?”- If no, go to the 5
R’s. If yes, proceed to ASSIST.
AASSIST: in setting up a quit date and offer pharmacologic as well as
behavioral support.
AARRANGE: a follow-up visit. Congratulate success or review circumstance
that led to relapse.
5 R’s – Enhance Motivation for Patients Unwilling to Quit5 R’s – Enhance Motivation for Patients Unwilling to Quit
RRELEVANCE: Tailor advice and discussion to each patient.
TEACHING POINTTEACHING POINT
FINDINGS
NOTES
BOOKMARKS
RRISKS: Discuss the risks of continued smoking, such as short- and long-
term personal health risks or harm to family.
RREWARDS: Discuss the benefits of quitting – live longer, save money, and
smell better while setting an example for your children.
RROADBLOCKS: Identify barriers to quitting – weight gain, withdrawal
symptoms, fear of failure, and depression.
RREPETITION: Reinforce the motivational message at every visit.
TOBACCO CESSATION COUNSELING CARE DISCUSSION
You and Dr. Griffin return to the exam room.
“Mr. Taleb, we recommend ibuprofen and an antihistamine called
chlorpheniramine to help with your symptoms. You can get them without a
prescription. If you don’t get better within the next week, or if you develop a
fever, give us a call.”
“Sure thing. I’m glad you took the time to explain why I don’t need
antibiotics.”
“Before you go, I want to remind you that the most important thing you can
do for your health is to stop smoking, and I strongly encourage you to quit. I
know it is hard, but I also know that you can do it! … Are you willing to give it a
try?”
“Thanks, Doc. I understand what you are saying about my overall health. I
am not sure I am ready to quit, but I’ll think about it. My kids are giving me
a hard time about smoking, too.”
“OK, but keep in mind that there are a lot of benects to quitting – you’ll feel
better, save money, and live longer. Besides that, your children will have a
healthier place to live.”
“Well, you might have a point there.”
You feel that he is in the contemplative stage, so you educate him about
the diseases associated with cigarettes. After a pause, you continue with
your questions to Mr. Taleb.
“You’ve quit three times before, and this tells me you can quit forever if you
want to. Are there things holding you back?”
“Well, I’m worried that I’ll get cranky and irritable and not stick with it. I’m
just not ready.”
“The truth is quitting isn’t easy, but it’s not impossible. There are
medications that can help with symptoms like craving and irritability, and we
will help you as much as we can. Just so you know, I’m going to talk to you about
this every time I see you!”
“Well, okay. Right now, though, I’m going to work on getting rid of this
cold! I’ll call you if I run into problems.”
You say goodbye to Mr. Taleb and wish him well.
Five Stages of Change
1. Precontemplation:Precontemplation: During this stage, patients do not even consider
changing. Smokers who are “in denial” may not see that the advice
applies to them personally.
2. Contemplation:Contemplation: During the contemplation stage, patients are
ambivalent about changing. Giving up an enjoyed behavior causes them
to feel a sense of loss despite the perceived gain. During this stage,
patients assess barriers (e.g., time, expense, hassle, fear, “I know I need
to, doc, but…”) as well as the benefits of change.
3. Preparation:Preparation: During the preparation stage, patients prepare to make
a specific change. They may experiment with small changes as their
determination to change increases, like sampling low-fat foods as a
move toward greater dietary modification.
4. Action:Action: The action stage is the one that most physicians are eager to
see their patients reach. Any action taken by patients should be praised
because it demonstrates the desire for lifestyle change.
5. Maintenance and relapse prevention:Maintenance and relapse prevention: Maintenance and relapse
prevention involve incorporating the new behavior “over the long haul.”
Discouragement over occasional “slips” may result in the patient giving
up. However, most patients find themselves “recycling” through the
stages of change several times before the change becomes truly
established.
TEACHING POINTTEACHING POINT
Tobacco Dependence
Fifteen percent of U.S. adults smoke, which is about 36.5 million people.
More than 16 million Americans live with smoking-related disease. One-third
of smokers die early from smoking-related illnesses, the most frequent being
coronary artery disease (33%), followed by lung cancer (28%), other lung
diseases (22%), and other cancers. People who smoke are at increased risk
of emphysema and chronic bronchitis as well as cardiovascular,
cerebrovascular and peripheral vascular disease.
Tobacco dependence is a chronic disease that often requires repeated
intervention and multiple attempts to quit. Successful quitters often made
multiple attempts before they were finally successful. Regardless of the
clinical setting in which you see a patient, you should address their smoking,
encourage them to quit, and help facilitate with medications and/or formal
counseling.
See the American Cancer Society for more information.
References
Scott McIntosh, University of Rochester Smoking Research Program & The American Academy of
Family Physicians National Research Network
TWO WEEKS LATER HISTORY
TEACHING POINTTEACHING POINT
http://www.cancer.org/Healthy/StayAwayfromTobacco/GuidetoQuittingSmoking/index
You explain the withdrawal symptoms to Mr. Taleb.You explain the withdrawal symptoms to Mr. Taleb.
!
Two weeks later, Dr. Griffin asks you to go in and see Mr. Taleb again. She is not
sure why he is here because the schedule just says “Follow-up”.
“Hi, Mr. Taleb. How are you doing?”
“I’m feeling just fine. You were right; I had a cold and I’m over it now.”
“What seems to be the problem today?”
“Well, I’d like to stop smoking cigarettes. My uncle, who smokes, just had a
heart attack, and I don’t want the same thing to happen to me. You
mentioned that there are things that can help make quitting easier. Can
we talk about them?”
“I’m so pleased you want to stop smoking! Yes, there are several medications
that can help with symptoms that occur with nicotine withdrawal. An exercise
program and family support can help, too. You told me before that your kids
are in favor of you quitting, so it sounds like you will have the family support
you need to be successful.”
“Will I gain weight?”
You explain to Mr. Taleb that the symptoms of withdrawal peak on the third
day after quitting, which makes this a risky time for relapse. “Weekends may be
difficult too, especially if you’re drinking alcohol or doing something associated
with smoking. I know you can do this if you keep at it!”
Symptoms of Nicotine Withdrawal
Craving cigarettes, insomnia, irritability, anxiety, poor concentration,
depression, and fatigue.
Symptoms peak on the third day after quitting.
SMOKING CESSATION THERAPEUTICS
The chemicals in cigarettesThe chemicals in cigarettes
!
Dr. Griffin joins you and is pleasantly surprised that Mr. Taleb is motivated to
quit smoking. She reiterates your previous message that quitting is the most
important step Mr. Taleb can take in improving his long-term health. She refers
Mr. Taleb to a smoking cessation group and then asks you which agent you
would prescribe.
Question
Which treatments are helpful for smoking cessation? Select all that
TEACHING POINTTEACHING POINT
The best options are indicated below. Your selections are indicated by
the shaded boxes.
apply.
A. Bupropion (Wellbutrin, Zyban)
B. Nicotine patch
C. Nicotine inhaler
D. Varenicline (Chantix)
E. Counseling
F. Hypnotherapy
G. Acupuncture/laser therapy
H. Quitting cold turkey
SUBMITSUBMIT
Answer Comment
> The correct answers are A, B, C, D, E> The correct answers are A, B, C, D, E
Hypnotherapy (F), acupuncture, and laser therapy (G) have not proven
to improve quit rates.
Management of Smoking Cessation
Several medications, such as buproprion (Wellbutrin,Several medications, such as buproprion (Wellbutrin,
Zyban), nicotine patches or inhalers, and vareniclineZyban), nicotine patches or inhalers, and varenicline
(Chantix), are helpful for smoking cessation and generally(Chantix), are helpful for smoking cessation and generally
improve quit rates from <10% to 20-30%, compared to self-improve quit rates from <10% to 20-30%, compared to self-
quitters (i.e., cold turkey).quitters (i.e., cold turkey). Nicotine replacement used optimally
and bupropion have comparable quit rates.
Varenicline (Chantix) is the newest smoking-cessation medication.
It is a nicotine acetylcholine receptor partial agonist, and in a
randomized controlled trial patients had better quit rates than
those who used bupropion. For varenicline, the quit rate was 45%
at three months compared to 34% for bupropion.The Food and
TEACHING POINTTEACHING POINT
Drug Administration (FDA) has put out warnings of
neuropsychiatric symptoms that occurred in patients who were
taking varenicline. Patients should be monitored for suicidal
ideation, increased agitation, vivid dreams, and depressed mood.
Counseling alone doubles quit rates, and counselingCounseling alone doubles quit rates, and counseling
combined with medications can improve quit rates to 30-combined with medications can improve quit rates to 30-
40%.40%.
References
Gonzales D, Rennard SI, Nides M et al. Varenicline an alpha4beta2 Nicotinic Acetylcholine
Receptor Partial Agonist vs Sustained-Release Bupropion and Placebo for Smoking Cessation: A
Randomized Controlled Trial. JAMA. 2006;296(1):47-55.
Jorenby DE, Hays JT, Rigotti NA, et al. Efficacy of Varenicline, an alpha4beta2 Nicotinic
Acetylcholine Receptor Partial Agonist vs Placebo or Sustained-Release Bupropion for Smoking
Cessation: A Randomized Controlled Trial. JAMA. 2006;296(1):56-63.
CHOICE OF DRUGS CARE DISCUSSION
Mr. Taleb says, “I’d like to take a medication that you recommend, rather than
quitting cold turkey, if the side effects aren’t too bad.”
But after Dr. Griffin informs him of the side effects, Mr. Taleb is hesitant to take
a medication daily so he opts for nicotine replacement therapy. You make a
plan to call him in one week, and he will be seen back in the office in one
month.
Side EUects of Tobacco Cessation Therapies
Nicotine replacements:Nicotine replacements:
Similar to those of excessive nicotine intake, including anxiety, nausea, and a
fast heart rate.
Tablets to be taken every day:Tablets to be taken every day:
1. Bupropion frequently causes insomnia and very rarely induces seizures.
TEACHING POINTTEACHING POINT
The best options are indicated below. Your selections are indicated by
the shaded boxes.
Check for history of seizures, head injuries, or eating disorders.
2. Varenicline can cause nausea, but patients should be advised that this is a
common side effect and that if they can tolerate a few days of nausea that it
should subside and not be a continued concern.
Question
Are there any contraindications to nicotine replacement? Select all
that apply.
A. Known CAD or stroke
B. Serious arrhythmia
C. Serious or worsening angina pectoris
D. Accelerated hypertension
E. Pregnancy
F. Recent myocardial infarction
G. Kidney disease
SUBMITSUBMIT
Answer Comment
> The correct answers are B, C, D, F> The correct answers are B, C, D, F
Nicotine Replacement Contraindications
Worsening cardiovascular disease is a contraindication toWorsening cardiovascular disease is a contraindication to
nicotine replacement. nicotine replacement. Serious arrhythmias (such asSerious arrhythmias (such as
ventricular tachycardia), worsening angina pectoris,ventricular tachycardia), worsening angina pectoris,
accelerated hypertension, and recent MI are allaccelerated hypertension, and recent MI are all
contraindications to nicotine replacement.contraindications to nicotine replacement.
TEACHING POINTTEACHING POINT
These are the only limitations to nicotine replacement therapy.
Studies of nicotine replacement therapy in pregnant females have
not identified negative health outcomes for mothers or their
babies, but there is still controversy over whether or not nicotine
replacement leads to higher rates of smoking cessation than
placebo. Nicotine replacement comes in many forms. The goal is to
replace nicotine to eliminate or reduce the physical withdrawal
symptoms. Nicotine patches should not be worn while smoking.
Nicotine gumNicotine gum
DOSE: Available in 2 or 4 mg pieces (4 mg is equivalent to one cigarette’s
nicotine). Used alone, up to 24 pieces a day can be chewed.
USE: Patient should put one piece in mouth and chew slowly until a peppery
taste occurs, then park the gum and take a chew every few minutes.
SIDE EFFECTS: Sore jaw and indigestion, especially if chewed too rapidly.
Nicotine inhalerNicotine inhaler
DOSE: Between 6 and 16 cartridges daily (each cartridge has 80 inhalations).
USE: Inhale cartridge for each craving. Satisfies hand-to-mouth behavior
craving.
Nicotine nasal sprayNicotine nasal spray
DOSE: One to two sprays each hour for 6-8 weeks.
ADVANTAGE: Quick delivery that emulates that of a cigarette.
Nicotine lozengesNicotine lozenges
DOSE: Available in 2 mg or 4 mg doses, similar to gum.
USE: One lozenge every 1-2 hours. Dissolves like hard candy.
Nicotine patchNicotine patch
DOSE: Comes in 7 mg, 14 mg and 21 mg patches. Patients who smoke a
pack per day should start at the 21 mg dose and taper every four weeks. A
patient who smokes two packs a day should start with two patches.
USE: Put the patch on the chest, back, or arms. Remove nightly and replace
in a different location.
SIDE EFFECTS: Irritation at patch site, which patients should be informed of,
with the explanation of that skin is a natural barrier that must be disrupted
to allow absorption of the nicotine into their system.
Please note: Please note: Combining the nicotine patch and a self-administeredCombining the nicotine patch and a self-administered
agent (nasal spray, lozenge or gum) is the most efficacious form ofagent (nasal spray, lozenge or gum) is the most efficacious form of
nicotine replacement.nicotine replacement.
Link to a site that shows examples of nicotine-replacement productsnicotine-replacement products.
References
Coleman T, et al. Pharmacological interventions for promoting smoking cessation during
pregnancy. Cochrane Database Syst Rev. 2015 Dec 22;(12).
FOLLOW-UP THERAPEUTICS
You call Mr. Taleb to ask how he is doing.You call Mr. Taleb to ask how he is doing.
!
http://www.mayoclinic.org/diseases-conditions/nicotine-dependence/diagnosis-treatment/treatment/txc-20202614
You recommend a nicotine patch at 14 mg/day for four weeks and then 7
mg/day for an additional four weeks. You also recommend that Mr. Taleb use 2
mg nicotine lozenges or gum as needed, but especially during the first week.
You write down the instructions for him to have at home.
Later in the week, you call Mr. Taleb to see how he is doing.
Mr. Taleb tells you, “Thanks for calling. Things are not going so well. My wife
lost her job, and I couldn’t afford the medications. But my friend at work said
his insurance covered bupropion, and he stopped smoking using it, so I want to
try that. My insurance should cover it, too.”
You confer with Dr. Griffin and plan to call the prescription in to the pharmacy.
You remind Mr. Taleb that exercise can help mitigate weight gain associated
with smoking cessation and counsel him on the use of a pedometer. You
arrange a follow-up visit with Mr. Taleb next week.
SUCCESS! HISTORY
Several months later, after finishing your rotation with Dr. Griffin, you call her
to update her after one of her patients has surgery. During your conversation,
she tells you that Mr. Taleb has been successful in his smoking cessation. He
finished the bupropion but he uses the nicotrol inhaler as needed when he
feels the urge to smoke. He still uses it several times weekly.
“Mr. Taleb said he couldn’t have quit smoking without your help and
encouragement.”
References
For some excellent information on smoking visit the CDC’s Office on Smoking and Health.
https://www.cdc.gov/tobacco/about/osh/index.htm
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” DEEP DIVEDEEP DIVE
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LEARNING OBJECTIVES LEARNING OBJECTIVES
QUESTION 1 SAQ
QUESTION 2 SAQ
QUESTION 3 SAQ
QUESTION 4 SAQ
QUESTION 5 SAQ
Thank you for completing Internal Medicine 15: 50-year-old male with
cough and nasal congestion.
South University College of Nursing and Public Health Graduate Online
Nursing Program
Aquifer Internal Medicine
Internal
Medicine
08: 55-year-
old male
with chronic
disease
management
Author/Editor:Author/Editor: Cynthia A. Burns, MD
INTRODUCTION HISTORY
You review Mr. Morales’ records on the computer.You review Mr. Morales’ records on the computer.
!
You are working with Dr. Clay in her outpatient diabetes clinic this morning.
https://southu-nur.meduapp.com/
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Your first patient, Mr. Morales, was seen by Dr. Clay once before, eight years ago,
but was lost to follow-up after that time.
Based on review of the electronic medical record you are able to collect the
following information prior to heading into the room to meet Mr. Morales:
Mr. Morales is a 55-year-old Hispanic male, diagnosed with Type 2
diabetes
mellitus thirteen years ago after experiencing a 20-pound unintentional weight
loss, blurry vision, and nocturia.
He was hospitalized six weeks ago with a non-ST elevation myocardial infarction
and required three vessel coronary artery bypass grafting. During his admission,
he was found to have a reduced ejection fraction of 20%.
He was referred for today’s visit by the cardiologist to focus on optimizing his
glycemic control and reducing his risk of the comorbidities associated with poorly
controlled Type 2 diabetes mellitus.
His last hemoglobin A1c (HbA1c) was 9.5% eight years ago, and he had
microalbuminuria at that time.
DIABETES CHRONIC DISEASE
MANAGEMENT
1
MANAGEMENT
You review diabetes chronic disease management with Dr. Clay.You review diabetes chronic disease management with Dr. Clay.
!
Before you see Mr. Morales, Dr. Clay reviews diabetes chronic disease
management with you.
Diabetes Chronic Disease Management
Evaluate for and optimize prevention of diabetic complicationsEvaluate for and optimize prevention of diabetic complications
Macrovascular complications:
Cardiovascular disease
Cerebrovascular disease
Microvascular complications:
Retinopathy
Nephropathy
Neuropathy
In particular, cardiovascular disease is the No. 1 cause of mortality for people
with diabetes, and one of the top causes of morbidity.
Hypoglycemia, infections, foot ulcers, and amputations are additional causes of
morbidity and mortality in patients with diabetes.
The American Diabetes Association publishes annual guidelines to assist in the
management of a patient with diabetes.
Remember the large role that the psychosocial aspects of a diabetesRemember the large role that the psychosocial aspects of a diabetes
diagnosis play in managementdiagnosis play in management
Non-adherence with medical recommendations could be due to economic,
work-related, religious, social, or linguistic barriers to care. Care must be taken
to assess the psychosocial status of each person with diabetes at each clinic
visit to ensure that barriers to successful diabetes care are minimized.
Question
Which of the following does the American Diabetes Association
recommend to minimize the risk of cardiovascular disease in patients
with diabetes? Select all that apply.
TEACHING POINTTEACHING POINT
http://care.diabetesjournals.org/content/41/Supplement_1
The best options are indicated below. Your selections are indicated by
the shaded boxes.
A. Smoking cessation
B. Daily aspirin therapy
C. Blood pressure less than 140/90 mmHg (if it can be
achieved without increased treatment burden, a systolic target of < 130
is appropriate in younger, healthier patients)
D. If > 40 years old, regardless of other atherosclerotic
cardiovascular disease risk factors, statin therapy
SUBMITSUBMIT
Answer Comment
> The correct answers are A, B, C, D> The correct answers are A, B, C, D
ADA Recommendations to Minimize the Risk of
Cardiovascular Disease in Patients with Diabetes
Smoking cessationSmoking cessation, daily aspirindaily aspirin, blood pressure controlblood pressure control and
lipid controllipid control are all recommended to reduce the risk of
cardiovascular disease.
Please note that as of 2018, ADA recommendations were published
with the older definition of hypertension (140/90). It always takes time
before multiple different organizations agree on the same thresholds.
Daily low dose aspirin is recommended for primary prevention of
cardiovascular disease in diabetic patients with a 10-year risk of
atherosclerotic cardiovascular disease of >10%. It is also
recommended for secondary prevention of all diabetic patients with a
history of atherosclerotic disease.
Reduction of cardiovascular risk is achieved with a goal of optimal
glycemic control, as well as control of many other health factors that
raise cardiovascular risk, such as tobacco use, obesity, poorly
controlled hypertension, and hypercholesterolemia.
TEACHING POINTTEACHING POINT
References
Economic Costs of Diabetes in the U.S. in 2012. American Diabetes Association. Diabetes Care. April
2013; 36(4):1033-1046. http://care.diabetesjournals.org/content/36/4/1033. Accessed May 11, 2018.
PATIENT HISTORY HISTORY
Mr. Morales tells you about his heart attack.Mr. Morales tells you about his heart attack.
!
You enter the exam room and introduce yourself to Mr. Morales.
“What brought you to the oRce today?”
“I had a heart attack about a month ago and had to have open-heart surgery.
The heart doctors told me that my heart is weak now. My cardiologist told me
that I have to get my blood sugar under control so I don’t have another heart
attack. I am here to get down to work.”
“Tell me more about that.”
“I didn’t come back to see Dr. Clay because my job at the furniture factory
wouldn’t give me time off for clinic appointments, and I couldn’t risk losing
” DEEP DIVEDEEP DIVE
http://care.diabetesjournals.org/content/36/4/1033
The best option is indicated below. Your selections are indicated by the
shaded boxes.
my job. I wasn’t checking my blood sugar before my heart attack because the
testing strips are so expensive and my supervisor wouldn’t let me off the line
to check anyway. Since my surgery, I haven’t gone back to work, and I’ve
been checking my sugar before each meal and before bed. The hospital
social worker got me two months’ worth of testing strips and lancets before I
went home, but I’m going to run out in a couple of weeks. I’m worried that I
won’t be able to check anymore.”
He also tells you that while he was in the hospital, they had to use insulin through
his vein to keep his blood sugar controlled, and that was very upsetting to him.
Question
True or False: In a critically ill medical patients, tight blood sugar control
with intravenous insulin therapy, with a goal blood sugar of 80-110
mg/dL, is associated with lower mortality than less tight blood sugar
control (e.g. 140-180 mg/dL).
A. True
B. False
SUBMITSUBMIT
Answer Comment
> The correct answer is B> The correct answer is B
EUectiveness of Intravenous Insulin for Blood Glucose
Control
Blood sugar control in critically ill patients has been the subject of
considerable investigation. Previous research suggested that tight
control (80-120 mg/dL) was desirable, but more recent research shows
that aggressive blood sugar control can be associated with higher
mortality.
Hypoglycemia (serum glucose concentration <70 mg/dL), with rates as high as 40% in some studies, is associated with tight glycemic control.
TEACHING POINTTEACHING POINT
A meta-analysis of 29 controlled trials involving more than 8,000 adult
ICU patients showed no difference in in-hospital mortality between the
group assigned to tight glucose control versus usual care.
The current recommended blood glucose target for mostThe current recommended blood glucose target for most
hospitalized patients is 140 to 180 mg/dL.hospitalized patients is 140 to 180 mg/dL.
References
Wiener RS, Wiener DC, Larson RJ. Benefits and risks of tight glucose control in critically ill adults: a
meta-analysis. JAMA. 2008;300(8):933.
MEDICATION REVIEW HISTORY
You review Mr. Morales’ medications with him:
MedicationsMedications
metformin 1000 mg twice daily
pioglitazone 15 mg daily
glipizide 5 mg daily
aspirin 81 mg daily
clopidogrel 75 mg daily
long-acting metoprolol 100 mg daily
furosemide 80 mg twice daily
lisinopril 20 mg daily
amlodipine 10 mg daily
ranitidine 150 mg twice daily
gabapentin 300 mg twice daily
potassium chloride 10 mEq twice daily
atorvastatin 80 mg daily
Mr. Morales says, “The hospital doctors sent me home on an insulin shot – 40 units
in my belly every night before I go to bed. I don’t like giving myself the shot, so
sometimes I just don’t, but I take all the rest of my medicines like they told me to.”
He takes out the vial of insulin, and you see that it is insulin glargine.
Question
The best option is indicated below. Your selections are indicated by the
shaded boxes.
Which of the following medications should you consider discontinuing in
this patient based on your knowledge of his reduced ejection fraction?
Choose the single best answer.
A. Pioglitazone
B. Atorvastatin
C. Aspirin
D. Glipizide
SUBMITSUBMIT
Answer Comment
> The correct answer is A> The correct answer is A
Thiazolidinediones
Pioglitazone (A),Pioglitazone (A), a member of the class of drugs known as
thiazolidinediones (TZD), is not recommended for use in patients who
have newly developed heart failure and in those with known NYHA
Class III and IV heart failure. The same is true for rosiglitazone, another
TZD that has been associated with an increased risk of cardiovascular
disease.
Mechanism of action:Mechanism of action: TZDs are peroxisome proliferator-activated
receptor-gamma (PPARgamma) agonists.
Effects:Effects: TZDs decrease insulin resistance, increase glucose uptake in
peripheral tissue, decrease hepatic glucose production, decrease
vascular inflammation, redistribute visceral adipose tissue
peripherally, and preserve beta cell function. Overall, they cause the
A1c to decrease by 1% to 1.5%. Hypoglycemia is not associated with
this medication class. TZDs have differing effects on lipids.
Pioglitazone slightly reduces LDL levels and raises HDL. Rosiglitazone
can increase LDL levels.
Side effects:Side effects: The receptors that TZDs activate are ubiquitous and are
TEACHING POINTTEACHING POINT
abundant in the cells within the renal collecting tubules. Hence, TZDs
increase sodium reabsorption, leading to increased water retention.
Compared to placebo, all TZDs are associated with a statistically
significant increase in edema and weight.
Warnings:Warnings: Care should be used with these agents in patients with
liver disease. Serum transaminases greater than 2.5 times the upper
limit of normal is a contraindication to initiation of these agents, and a
rise to greater than three times the upper limit of normal should lead
to their discontinuation. Liver tests should be measured at baseline
and periodically while the patient is on this class of medication.
Contraindications:Contraindications: The FDA has added a warning to the label of
pioglitazone noting an increased risk of bladder cancer after more
than one year of treatment. Pioglitazone is now contraindicated in
patients with a history of bladder cancer or active bladder cancer.
Patients should be counseled to tell their physician if they notice blood
in their urine or a red tint to their urine.
No precautions are needed when using aspirin, glipizide, or simvastatin
in patients with a reduced ejection fraction.
BLOOD GLUCOSE MONITORING HISTORY
” DEEP DIVEDEEP DIVE
!
You continue your interview with Mr. Morales and ask him:
“Have you brought your blood sugar log with you today?”
He hands you his blood sugar log proudly. Over the last four weeks, you see
that his morning fasting readings are ranging 130-169 mg/dL, including
before-lunch readings of 151-247 mg/dL, before-supper readings of 184-211
mg/dL, and before-bed readings of 158-305 mg/dL. There are no recorded
readings under 70 mg/dL (3.9 mmol/L).
“Some days you have many readings over 200 mg/dL. Is there anything
diUerent going on on those days that you can think of such as eating larger meals?”
“Oh, those are the days after I didn’t take my insulin shot. The readings are
always higher on those days.”
“Have you had any low blood sugars?”
“I feel like I have low blood sugar several times a week, and I eat a Snickers
bar because I’m afraid of passing out and going into a coma. I feel like I’m
going to die — shaky, sweaty, jittery! I don’t check when I feel this way, I just
eat as fast as I can – I can tell when my sugar is low.”
See the associated reference ranges in conventional and SI units.
https://www.meduapp.com/resources/laboratory_reference_values
The best option is indicated below. Your selections are indicated by the
shaded boxes.
Hypoglycemia
It is important at each visit to ask diabetic patients if they have experienced any
hypoglycemic symptoms or events that required the assistance of another
person.
Often times, when a patient is hypoglycemic, he does not write it down because
he is preoccupied treating the hypoglycemia.
When to Refer Patients with Diabetes to an Endocrinologist
If a patient is having recurrent or severe hypoglycemia (seizure, coma, or
impairment that requires the aid of another person), an endocrinologist should
be consulted. Hypoglycemia is defined as a blood glucose <70 mg/dL.
Primary care physicians’ threshold for referral varies across providers. Other
conditions that would warrant referral are when a patient’s A1c is 8% more than
twice in a 12-month period, despite intensive treatment; for initiation of a
complex multiple daily injection insulin regimen; or for initiation of continuous
infusion insulin pump
therapy.
Question
Can patients accurately detect hypoglycemia by symptoms alone?
A. Yes
B. No
SUBMITSUBMIT
Answer Comment
> The correct answer is B> The correct answer is B
Self-Monitoring Glucose: Indications & EUectiveness
TEACHING POINTTEACHING POINT
TEACHING POINTTEACHING POINT
TEACHING POINTTEACHING POINT
Self-Monitoring Glucose: Indications & EUectiveness
Effectiveness of Self-Monitoring Blood GlucoseEffectiveness of Self-Monitoring Blood Glucose
Patients should be advised to check their blood sugar if they feel “low”
because it is well recognized that people are not able topeople are not able to
accurately detect hypoglycemia (blood glucose of < 70 mg/dL)accurately detect hypoglycemia (blood glucose of < 70 mg/dL)
by symptoms aloneby symptoms alone. Eating high carbohydrate food to treat
perceived hypoglycemia rather than actual hypoglycemia leads to
worsened overall glycemic control.
Clinical studies have shown that self-monitoring of blood glucose
(SMBG) may improve glycemic control, although for some patients
self-monitoring increases depression and anxiety. It is important to
evaluate patients’ abilities to use SMBG techniques to ensure they are
using accurate data to evaluate their response to therapy and their
degree of success in reaching blood-glucose targets. After receiving
education, patients can use SMBG data to adjust their activity level,
food intake and choice, as well as drug therapy to achieve optimal
glycemic control.
When to Self-Monitor Blood GlucoseWhen to Self-Monitor Blood Glucose
In patients on less frequent insulin injections, SMBG may be useful in
achieving glycemic goals.
Patients on an insulin pump and those using multiple daily insulin
injections should self-monitor blood glucose at the following times:
before each meal
at bedtime
when they have symptoms of hyper- or hypoglycemia
after treating hypoglycemia to ensure return of euglycemia
before exercise
before critical activities, such as driving
Blood Glucose Goals
HealthyHealthy *Medically*Medically
**Very**Very
MedicallyMedically
TEACHING POINTTEACHING POINT
AdultsAdults
ComplexComplex
AdultsAdults
ComplexComplex
AdultsAdults
fasting andfasting and
beforebefore
mealsmeals
80-130
mg/dL (3.9-
7.2 mmol/L)
90-150
mg/dL
100-180 md/dL
one to twoone to two
hours afterhours after
a meala meal
< 180 mg/dL (10.0 mmol/L)
before bedbefore bed
100-130
mg/dL (5.6-
7.2 mmol/L)
100-180
mg/dL
110-200 mg/dL
*Medically complex adults have multiple co-existing chronic illnesses,
two or more ADL impairments, or mild to moderate cognitive
impairment.
**Very medically complex adults or adults in poor health have long
term care or end-stage chronic illnesses, moderate to severe cognitive
impairment, or two or more ADL dependencies.
See the associated reference ranges in conventional and SI units.
DIET HISTORY HISTORY
You ask Mr. Morales about diet and physical activity.
“Can you tell me what you typically eat in a day?”
“I usually eat breakfast and lunch at McDonald’s or Denny’s. For breakfast, I
usually have a bacon egg and cheese biscuit with hash browns and black
coffee. For lunch, I have a sandwich, fries, and soda. If I’m really hungry, I get
the “value” size of the fries and soda.”
” DEEP DIVEDEEP DIVE
https://www.meduapp.com/resources/laboratory_reference_values
The best options are indicated below. Your selections are indicated by
the shaded boxes.
“What drinks and snacks do you typically eat during the day?”
“I drink Coke with lunch, whole milk with supper, and usually have a big bowl
of fudge ripple ice cream before I go to bed. If I’m hungry in the afternoon, I’ll
grab a pack of cookies from a vending machine.”
“And what do you have for dinner?”
“My wife and I eat supper at home. We share the cooking. Usually, we have
fried or stewed meat with gravy, rice, or pasta along with rolls. Sometimes we
have vegetables cooked with side meat.”
“Are you able to do any exercise during the week?”
“Except for moving around at work, I didn’t get much exercise before. Since
my heart surgery, I feel short of breath just walking to the mailbox at the end
of the driveway!”
“Do you have any chest pain or sweating?”
“Not really.”
SCREENING FOR COMPLICATIONS HISTORY
You now decide to focus your history on screening for complications of diabetes:
“Are you having any trouble with your vision?”
“How about numbness or tingling in your hands or feet?”
Question
Which of the following are types of neuropathies a patient with diabetes
might develop? Select all that apply.
A. Distal symmetric polyneuropathy
B. Postural hypotension
C. Gastroparesis
D. Erectile dysfunction
E. Resting tachycardia
SUBMITSUBMIT
Answer Comment
> The correct answers are A, B, C, D, E> The correct answers are A, B, C, D, E
Diabetic Neuropathies
It is estimated that 50% of patients with diabetes will eventually
struggle with one or more neuropathies related to their diabetes.
Axonal loss and atrophy are responsible for the majority of clinical
symptoms and loss of function in patients with neuropathy. There can
also be evidence of demyelination and remyelination, with the actual
number of large nerve fibers being reduced, while small nerve fibers
increase.
Distal polyneuropathyDistal polyneuropathy
Distal polyneuropathy is the most common type of diabetic
neuropathy. It is the progressive loss of sensation in the classic
stocking/glove distribution. Diabetic foot ulcer incidence is greatly
increased in patients with distal polyneuropathy.
Autonomic neuropathyAutonomic neuropathy
Autonomic neuropathy can take many forms and affect one or many
organs. Specific types include:
cardiovascular (orthostatic hypotension, resting sinus tachycardia,
postprandial hypotension)
gastrointestinal (gastroparesis, chronic constipation, esophageal
motility disorders)
genitourinary (sexual dysfunction, neurogenic bladder)
TEACHING POINTTEACHING POINT
abnormal pupillary responses and disorders of hidrosis
OBESITY MANAGEMENT MANAGEMENT
You leave the room so that Mr. Morales can disrobe for your exam. Dr. Clay asks
what you have learned so far.
You present the history to Dr. Clay and tell her that you are particularly concerned
about Mr. Morales’ diet. You and Dr. Clay look at the triage sheet and see that Mr.
Morales’ height is 176.5 cm (69.5 inches) and his weight is 123 kg (272 lbs). You
calculate his BMI: it is 39.6 kg/m .
2
Body Weight Management in Patients with Diabetes
ClassificationClassification BMI in kg/mBMI in kg/m22
Normal 19-24
Overweight 25-29
Obese 30-39
Morbidly obese 40+
Maintenance of a healthy body weight is essential in the management of
patients with diabetes. However, for some patients, attainment of an ideal body
weight is too large a goal, especially if they are morbidly obese. Studies have
shown that a modest weight loss of approximately 5-10%modest weight loss of approximately 5-10% of the current
weight can lead to significant improvement in glycemic control, blood pressure
control, and lipid parameters.
Question
” DEEP DIVEDEEP DIVE
TEACHING POINTTEACHING POINT
The best options are indicated below. Your selections are indicated by
the shaded boxes.
Which of the following are appropriate approaches to addressing Mr.
Morales’ obesity and diet? Select all that apply.
A. Referral to a registered nutritionist for medical nutrition
therapy.
B. Office-based, brief dietary counseling.
C. Referral to an accredited diabetes care center for diabetes
management self education.
D. Patient materials about diet and exercise.
SUBMITSUBMIT
Answer Comment
> The correct answers are A, B, C, D> The correct answers are A, B, C, D
Mulitdisciplinary Approach to Diabetes Care
The care of the patient with diabetes is a team endeavor. Through a
multidisciplinary approach, patients can be offered the very best
chance of optimizing their blood glucose control and reducing their
risks of morbidity and mortality.
Refer to a registered nutritionist for medical nutrition therapy
regarding daily food choices and portion sizes.
Refer to an accredited diabetes care center for diabetes
management self-education, both in group and one-on-one settings.
Numerous studies have shown that diabetes management self-
education is effective in improving patients’ self-care behaviors,
lowering their A1c, improving their knowledge of diabetes and
enhancing their quality of life.
Office-based counseling of basic ADA recommendations for diet and
exercise can be reviewed with the patient. For example, patients can
be taught how to monitor his carbohydrate intake through
carbohydrate counting, food exchanges, or self-reflection. Thirty
minutes of moderately intense exercise, more days than not, may be a
good recommendation for many patients. Less than 10% of daily
TEACHING POINTTEACHING POINT
calories should be from fat.
Patient education materials are a useful adjunct to office-based
counseling, and can be found at the ADA website section on
diet/exercise.
BLOOD PRESSURE MANAGEMENT MANAGEMENT
You recheck Mr. Morales’ blood pressure manually.You recheck Mr. Morales’ blood pressure manually.
!
You look at the rest of Mr. Morales’ vital signs:
Vital signs:Vital signs:
Temperature:Temperature: 36.3 C (97.9 F)
Pulse:Pulse: 74 beats/minute
Respiratory rate:Respiratory rate: 12 breaths/minute
Blood pressure:Blood pressure: 152/86 mmHg today (148/92 mmHg at the cardiologist’s office
two weeks ago)
Fingerstick blood glucose:Fingerstick blood glucose: 158 mg/dL (8.8 mmol/L)
You retake his blood pressure manually and read 150/90 mmHg.
See the associated reference ranges in conventional and SI units.
http://www.diabetes.org/food-and-fitness/?utm_source=WWW&utm_medium=GlobalNavFF&utm_campaign=CON
https://www.meduapp.com/resources/laboratory_reference_values
The best option is indicated below. Your selections are indicated by the
shaded boxes.
Question
Is this patient’s blood pressure at goal?
A. Yes
B. No
SUBMITSUBMIT
Answer Comment
> The correct answer is B> The correct answer is B
Blood Pressure Goal for Patients with Diabetes
There is ample, well-validated evidence that blood pressure control is
one way of lowering a diabetic patient’s cardiovascular risk. According
to the ADA, the optimal blood pressure goal in patients with diabetes
is less than 140/90 mmHg. Younger, healthier patients who can be
treated without increasing the treatment burden may have a lower
systolic target, such as less than 130. It is important to remember that
an individual patient’s blood pressure goal may be higher or lower
based on his/her response to therapy and personal characteristics.
Note: Other organizations recommend different blood pressure goals
for patients with diabetes, such as the ACC/AHA, which recommends
treatment in people with diabetes who have blood pressure greater
than or equal to 130/80 mmHg, with a goal blood pressure of less than
130/80 mmHg.
The ACC/AHA guidelines on hypertension published in late 2017
suggested lower numbers for a definition of HTN; now anything over
130/80 is considered hypertension per ACC/AHA. Other organizations –
like ADA – have not yet updated their guidelines to reflect this change.
Pharmaceutical managementPharmaceutical management
Most diabetic patients require multiple agents to reach and maintain
their individual blood pressure goal. ACE inhibitor and ARB therapy
TEACHING POINTTEACHING POINT
are first-line treatment options because they also delay the onset and
decrease the progression of diabetic nephropathy. Diuretics and
calcium channel blockers can be used to attain blood pressure goals.
Reasons for uncontrolled blood pressureReasons for uncontrolled blood pressure
There are multiple reasons why a patient may have uncontrolled
blood pressure. Blood pressure may be uncontrolled in patients
needing increased dosages of their medications or additional agents.
It may be elevated secondary to medications (e.g. NSAIDs) or alcohol.
Or patients may not be taking their medications regularly, may not
have taken their medications on the day of the office visit, or may have
run out of their medication prior to the visit.
Before adding another medication or increasing the dose of existing
medication, it is critical that nonadherence be explored first as a
possible cause of uncontrolled hypertension.
When asked about his adherence to his current regimen, Mr. Morales
says he took all of his medications this morning and did not miss any
doses of his medications in the past week.
PHYSICAL EXAM 1 PHYSICAL EXAM
You examine Mr. Morales’ eyes.You examine Mr. Morales’ eyes.
!
You proceed with Mr. Morales’ exam, paying special attention to the fundoscopic
exam.
Physical ExamPhysical Exam
GeneralGeneral: Obese, older male in no apparent distress.
HEENTHEENT: Normocephalic, atraumatic. Oropharynx clear and moist. Dentition and
dental hygeine good. Pupils equal and reactive to light and accommodation.
Extraocular movements intact. No icterus.
Fundoscopic examFundoscopic exam: Several microaneurysms bilaterally and hard exudates on
the left.
NeckNeck: Supple and thick. No increased JVD. No carotid bruits. Carotid pulses 2+
bilaterally with normal upstroke. No thyromegaly or masses.
LungsLungs: Clear to auscultation bilaterally. No wheeze, rales, or rhonchi.
CardiacCardiac: PMI diffuse and laterally displaced. Regular rate and rhythm. Normal S1,
S2, no S3, no S4, no murmurs.
AbdomenAbdomen: Soft, nontender, nondistended, no hepatosplenomegaly.
The best options are indicated below. Your selections are indicated by
the shaded boxes.
Question
Which of the following are recommendations for the prevention and
decreased progression of diabetic retinopathy? Select all that apply.
A. Optimal blood pressure control
B. Optimal glucose control
C. Smoking cessation
D. Optimal LDL control
SUBMITSUBMIT
Answer Comment
> The correct answers are A, B, C> The correct answers are A, B, C
Diabetic Retinopathy
Diabetic retinopathy, a microvascular diabetic complication, is the
leading cause of preventable blindness in the developed world.
PreventionPrevention
Two large prospective trials (DCCT with Type 1 diabetics and UKPDS
with Type 2 diabetics) revealed that intensive glucose management
resulted in prevention or delayed onset and progression of diabetic
retinopathy.
Co-existing hypertension, nephropathy, and tobacco abuse also
contribute to retinopathy onset and progression.
Two types of diabetic retinopathyTwo types of diabetic retinopathy
1. Non-proliferative diabetic retinopathyNon-proliferative diabetic retinopathy
Involves cotton wool spots, hard exudates, microaneurysms, and
retinal hemorrhages.
TEACHING POINTTEACHING POINT
https://medu-relier-production.s3.amazonaws.com/files/SIMPLE-08-c2HsB1o7coAFhzTur-Z5A2MUkASComz6CQVw5pWjneKqY6ACxrW/compressed/images/251192
Vision loss usually results from severe macular edema, a thickening of
the retina with resultant edema of the macula.
2. Proliferative diabetic retinopathyProliferative diabetic retinopathy
Involves neovascularization of the retinal vessels or optic disc, retinal
hemorrhage (dot-blot, flame), retinal fibrosis with traction
detachment, and vitreous hemorrhage. Macular edema can occur as
well.
Image of proliferative retinopathy with neovascularizationImage of proliferative retinopathy with neovascularization
!
OnsetOnset
Development of diabetic retinopathy is directly related to disease
duration and is generally not seen in patients who have had diabetes
less than five years. The exception is Type 2 diabetic patients who
were likely hyperglycemic more than five years prior to their diabetes
diagnosis.
ScreeningScreening
Annual dilated eye exams by an ophthalmologist are recommended
for all Type 1 diabetic patients within five years of diagnosis and
shortly after diagnosis in patients with Type 2 diabetes. Patients with
progressive retinopathy are often seen quarterly or biannually.
Panretinal TreatmentPanretinal Treatment
Panretinal laser photocoagulation is the treatment of choice for
proliferative diabetic retinopathy and severe cases of non-proliferative
retinopathy. Screening is done aggressively due to the well-
documented efficacy of laser photocoagulation in the prevention of
vision loss. Ranibizumab, an anti-vascular endothelial growth factor,
injected into the vitreous showed noninferiority to laser therapy and
can also be used.
PHYSICAL EXAM 2 PHYSICAL EXAM
You perform a diabetic foot exam on Mr. Morales.You perform a diabetic foot exam on Mr. Morales.
!
You are glad you will have the opportunity to practice the diabetic foot exam you
reviewed last night.
” DEEP DIVEDEEP DIVE
You proceed with Mr. Morales’ exam:
Physical ExamPhysical Exam
Extremities:Extremities: Full range of motion without clubbing or cyanosis. No peripheral
edema.
Diabetic foot exam:Diabetic foot exam: 1+ dorsal pedis and posterior tibialis pulses bilaterally
with decreased sensation to monofilament and vibration to the mid-shin. No
ulcers. + diffuse onychomycosis.
Neurologic:Neurologic: Awake, alert and oriented times four. Cranial nerves II-XII are
grossly intact. Muscle strength is 5/5 throughout with normal tone and bulk. Deep
tendon reflexes are trace throughout. Gait normal. No tremor.
When to Perform the Diabetic Foot Exam
It is important to do a thorough foot exam in a diabetic patient on an annual
basis for low-risk patients and more often in patients at high risk for foot ulcer
formation.
Patients at High Risk for foot Ulcer FormationPatients at High Risk for foot Ulcer Formation
Patients with known diabetic polyneuropathy, sensory or vascular deficits,
patients who smoke, and patients with a prior history of diabetic foot ulcer or
amputation.
Foot Exam in Patients with Diabetes
Visually inspect the feet for callus formation, ulceration, nail infections, and
bony deformities.
Assess skin integrity, especially between toes and under metatarsal heads.
Palpate the dorsalis pedis and posterior tibialis pulses to screen for peripheral
vascular disease and look for signs of peripheral vascular disease, such as hair
loss.
Check sensation using a 128 Hz tuning fork (vibration) and a cool metal object,
potentially the same tuning fork (temperature).
Check pressure sensation using a 10-g monofilament:
TEACHING POINTTEACHING POINT
TEACHING POINTTEACHING POINT
Show the monofilatment to the patient and try it on their hand to show them
it will not hurt.
Ask the patient to close their eyes or look at the ceiling and tell you each time
they feel the monofilament touch their foot.
Randomly place the end of the monofilament on the 9 different areas of the
foot (see image to the right) with enough pressure to bend the monofilament.
If the patient does not say “yes” at a particular site, continue to the next site
and re-test that site at the end.
Check achilles reflexes.
Question
List some of the preventive measures will you recommend to Mr.
Morales regarding foot care.
The suggested answer is shown below.
Letter Count: 0/1000
SUBMITSUBMIT
Answer Comment
Foot Care for Patients with Diabetes
It is important to review and provide information about foot self-care
TEACHING POINTTEACHING POINT
http://diabetes.niddk.nih.gov/dm/pubs/complications_feet
with diabetic patients.
Patients should be instructed to check the dorsal and plantar
surfaces of their feet everyday for cuts, sores, redness, and swelling.
If the patient is unable to view his entire foot by himself, then a
caregiver should be asked to do it for him.
Feet should be washed daily and dried well.
Remind patients to use their forearm to check water temperature to
prevent burns.
Patients should keep the skin of their feet smooth and soft with
lotion.
Toenails should be trimmed weekly or as needed.
Patients should be encouraged to wear white socks, as these will
show any drainage from a previously unknown sore, and well-fitting,
comfortable shoes.
Shoes and socks should be worn at all times.
There is no robust evidence to warrant the recommendation that all
patients with diabetes be fitted with special shoes to prevent diabetic
foot ulcers.
High-risk patients should be referred to a podiatrist for
comprehensive foot care.
DIABETES LAB EVALUATION TESTING
” DEEP DIVEDEEP DIVE
The best options are indicated below. Your selections are indicated by
the shaded boxes.
You discuss the next steps for Mr. Morales with Dr. Clay.You discuss the next steps for Mr. Morales with Dr. Clay.
!
You tell Mr. Morales that you are finished with your exam and explain that after
you talk with Dr. Clay, you’ll both be back. You step out and present the findings
from your physical exam to Dr. Clay. The two of you start to discuss the next steps
for Mr. Morales.
Question
Which of the following laboratory studies are appropriate to order for
Mr. Morales today? Select all that apply.
A. Hemoglobin A1c
B. Fasting lipid profile
C. Liver function profile
D. Basic metabolic profile
E. Spot urine albumin/creatinine ratio
SUBMITSUBMIT
Answer Comment
Answer Comment
> The correct answers are A, B, C, D, E> The correct answers are A, B, C, D, E
All tests listed are appropriate because Mr. Morales has not had these
tests in the last year. A reasonable A1c goal for a patient such as Mr.
Morales with prevalent coronary artery disease would likely be 7-8%.
Chronic Diabetes Evaluation
Hemoglobin A1cHemoglobin A1c
Hemoglobin A1c should be ordered every six months in patients
who are meeting their individualized treatment goals, and every three
months if they are not or if therapy is changing.
A HbA1c goal of < 7% is generally a reasonable goal for a nonpregnant, otherwise healthy adult patient. More stringent A1c goals (< 6.5%) may be appropriate in some patients, with shorter disease duration, long life expectancy, and no significant cardiovascular disease, if it can be attained without significant hypoglycemia.
The ADA Standards of Medical Care in Diabetes state, “less stringent
A1c goals (such as < 8%) may be appropriate for patients with history
of severe hypoglycemia, limited life expectancy, advanced
microvascular or macrovascular complications, extensive comorbid
conditions, and those with longstanding diabetes in whom a stringent
goal is difficult to attain." For patients who have limited resources and
a poor support system, and/or are unable to prioritize self-care due to
social, economic or psychological stressors, a less stringent A1c goal
may also be appropriate.
Remember that HbA1c levels are unreliable in patients with
hemoglobin variants, such as sickle cell disease; with end-stage kidney
failure/on dialysis, and who have recently had blood transfusions or
large blood loss.
Individuated Hemoglobin A1c Goals
Healthy Nonpregnant Adults, without severe recurrent
hypoglycemia/hypoglycemic unawareness
< 7%
Medically Complex Adults, with history of severe
TEACHING POINTTEACHING POINT
hypoglycemia and/or longstanding diabetes < 8%
Medically Complex Adults/Adults in Poor Health, with
severe recurrent hypoglycemia/hypoglycemic
unawareness
< 8.5%
Fasting lipid profileFasting lipid profile
The ADA and the AHA/ACC are overall in agreement regarding lipid
management in diabetic patients.
The AHA/ACC guidelines are:The AHA/ACC guidelines are:
Lifestyle modification (weight loss, increased physical activity,
reduced fat intake) should be recommended for all patients with
diabetes, where appropriate.
All patients with diabetes and cardiovascular disease, regardless of
age, should be on a high intensity statin.
All patients aged 40 to 75 with diabetes should be on a moderate-
intensity statin. If ASCVD risk is >7.5%, they should be on a high-
intensity statin.
For patients aged <40 or >70 with diabetes, consider statin therapy
depending on risks/benefits and patient preferences.
The ACC/AHA does not recommend lipid goals at this point.
See the requiredrequired Aquifer Cholesterol Guidelines module for more
information about this.
Liver function profileLiver function profile
Indicated if the patient takes a TZD. When patients take this class of
medication, liver tests should be monitored periodically.
Basic metabolic profileBasic metabolic profile
Indicated to monitor renal function if the patient takes metformin
and in patients with diabetes in general.
Spot urine albumin/creatinine ratioSpot urine albumin/creatinine ratio
Indicated annually in patients with Type 2 diabetes without evidence
of increased urinary albumin excretion (<30 mcg albumin/mg
creatinine) and more often to assess for progression and effect of
DIAGNOSES
FINDINGS
NOTES
MENUMENU
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therapy in patients with established increased urinary albumin
excretion (30 mcg albumin/mg creatinine or greater). A diagnosis of
increased urinary albumin excretion is made when two of three
specimens collected within a 3- to 6-month period are 30 mcg/mg
creatinine or greater. Remember that vigorous exercise within the last
24 hours, menstruation, illness, fever, markedly elevated blood
pressure, CHF exacerbation, and acute hyperglycemia can cause false-
positive results.
Urine dipstick measurements are not used to diagnose or follow
increased urinary albumin excretion because of the insensitivity of the
method for detecting the initial small increases in protein excretion.
Protein excretion must exceed 300 mcg per day to turn the dipstick
positive.
Estimated GFR based on the serum creatinine should also be used to
assess for chronic kidney disease, at least annually, looking at
declining GFR as another marker of kidney disease progression.
See the associated reference ranges in conventional and SI units.
CONCLUDING THE VISIT CARE DISCUSSION
” DEEP DIVEDEEP DIVE
BOOKMARKS
https://www.meduapp.com/resources/laboratory_reference_values
The best options are indicated below. Your selections are indicated by
the shaded boxes.
Mr. Morales explains his frustration with quitting smoking.Mr. Morales explains his frustration with quitting smoking.
!
You and Dr. Clay return to speak with Mr. Morales. Dr. Clay spends time catching
up with him, clarifying some parts of the history and performing her own physical
exam.
She then asks, “How’s the smoking going?”
He responds, “I know I need to stop smoking, Dr. Clay. I’ve cut down to less than
half a pack a day, but I just can’t quite seem to do it.”
She encourages him, “We’ll help you come up with a plan for stopping completely.
We know that you can do it!”
Dr. Clay asks Mr. Morales to get redressed and go to the lab to have some blood
drawn. She directs him to return to the exam room when he is finished so you can
discuss the next steps for his care together.
Question
Which of the following recommendations should be given to Mr. Morales
today? Select all that apply.
A. Discontinue metformin.
B. Attempt smoking cessation (with help in putting a plan in
place).
C. Increase lisinopril to 40 mg daily, and return to the lab for a
potassium and creatinine measurement in one week.
D. See a dentist every other year.
E. Pneumococcal vaccination.
F. Influenza vaccination.
G. Return to clinic in six months.
SUBMITSUBMIT
Answer Comment
> The correct answers are A, B, C, E, F> The correct answers are A, B, C, E, F
Smoking Cessation in the Setting of Diabetes
Complete smoking cessation is the goal in all patients, and smoking
cessation counseling should be part of every clinic visit. Merely asking
if the patient is considering smoking cessation increases the chance
that the patient will quit. Patients who have already cut down should
be congratulated on accomplishing that hard task, then they should be
encouraged to build on this success and quit completely.
Studies have shown that diabetic smokers suffer far more
cardiovascular comorbidity than patients without diabetes who smoke
and that smoking cessation leads to decreased progression of
retinopathy and nephropathy.
Vaccinations for Patients with Diabetes
Diabetic patients should receive a pneumococcal vaccination and
should be immunized for influenza annually. They should also receive
the Hepatitis B vaccine series if they are between 19 and 59 years old.
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Dental Care for Patients with Diabetes
Diabetic patients should be seen by a dentist regularly; the
recommendation is twice a year.
Metformin Contraindications
Metformin is not recommended for patients with reduced ejection
fraction requiring pharmacologic therapy, in particular patients with
unstable or acute heart failure. It is likely safe in patients with well-
compensated, stable CHF. It is prudent to stop a patient’s metformin
in the setting of a recent heart failure diagnosis but it may also be
reasonable to restart it in the future should their symptoms stabilize.
Metformin is also contraindicated in patients with a GFR of < 30 mL/min/1.73m . In addition, it shouldn't be started in patients with a GFR of 30 to 45 mL/min/1.73m though can be continued at a reduced dose with a GFR in this range in patients started on the medication when kidney function was normal. It is also contraindicated in patients with alcohol abuse or marked liver disease. These contraindications exist due to the increased risk of lactic acidosis in these patients. Metformin should be routinely discontinued when patients are hospitalized due to the increased risk of dehydration and opportunity for IV contrast dye use, which could reduce renal function.
2
2
Increase lisinopril to 40 mg daily (C)Increase lisinopril to 40 mg daily (C): Mr. Morales’ blood pressure is
above goal, so increasing his ACE inhibitor will hopefully lower his blood
pressure while affording renal protection and decreasing urinary
albumin excretion. It is prudent to evaluate for hyperkalemia and a
further increase in creatinine in one week, given that both are known
side effects of ACE inhibitor therapy.
Mr. Morales’ A1c is likely not at goal of 7% to 8%, and today you are
discontinuing his metformin and pioglitazone. He is likely going to need
additional hypoglycemic agents to lower his blood glucose, perhaps
prandial insulin. Waiting six months to see him again (G) puts him at
great risk of incurring additional co-morbidity from poorly controlled
Type 2 diabetes. He should be seen in two to four weeks to ensure that
TEACHING POINTTEACHING POINT
TEACHING POINTTEACHING POINT
additional agents are added in a timely manner if necessary.
See the associated reference ranges in conventional and SI units.
MEDICATIONS TO TREAT DIABETES TEACHING
Dr. Clay uses this as an opportunity to teach you a little bit about oral and
injectable medications that are used in the management of the Type 2 diabetic
patient.
Injectable Medications for Type 2 Diabetes
InsulinInsulin
Different types of insulin are used to manage diabetes.
The ADA Standards of Medical Care in Diabetes state, “consider initiating insulin
therapy (with or without additional agents) in patients with newly diagnosed
Type 2 diabetes who are symptomatic and/or have A1c 10% or greater and/or
blood glucose levels 300 mg/dL or greater.”
Evidence is accumulating that earlier use of insulin in the treatment of patients
with uncontrolled Type 2 diabetes results in better long-term glycemic control.
In a patient with an A1c value 9% or greater, oral hypoglycemic and non-insulin
injectable medications as monotherapy are unlikely to bring the patient’s A1c to
goal, and dual therapy is recommended.
When insulin is used, typically a basal insulin, such as glargine or detemir, is
initiated first, with continuation of one or more oral medications (usually
metformin, unless there is a contraindication). The regimen is then escalated
every three to six months until the A1c goal is attained.
In patients on a single oral agent whose A1c is within one percentage point of
goal, adding another oral agent or non-insulin injectable should be considered.
A well-known meta-analysis found that for each non-insulin agent added from a
different class, the A1c could be expected to decrease 0.9-1.1%.
For a comprehensive list of available insulins refer to table 8.2: Pharmacology of
available glucose-lowering agents in the U.S. for the treatment of type 2
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diabetes
Glucagon-like peptide-1 receptor agonistsGlucagon-like peptide-1 receptor agonists
Mechanism of action:Mechanism of action: There are several GLP-1 receptor agonists available,
commonly prescribed agents include exenatide and liraglutide. These agents
increase insulin secretion in a blood glucose dependent manner. They also
decrease post prandial glucagon secretion, slow gastric emptying, centrally
increase satiety, and decrease appetite. *
Administration:Administration: These agents are all delivery by subcutaneous injection.
There are monthly, weekly, daily and twice daily formulations. They can be used
in combination with most oral medications and with basal insulin. *
Side effects:Side effects: The most common side effect is nausea, which can be
significant, accompanied by emesis. *
Effects:Effects: A1c decreases of approximately 1% and statistically significant
weight loss are associated with use.
Contraindications:Contraindications: There have been post marketing reports of exenatide-
induced pancreatitis, so its use in patients with a history of pancreatitis should
be avoided. Tumors of the C-cells have been reported.
References
American Diabetes Association Standards Of Medical Care In Diabetes-2018. Diabetes Care. 2018 Jan;
41 (Supplement 1): S1-S2. http://care.diabetesjournals.org/content/41/Supplement_1. Accessed May
4, 2018.
American Diabetes Association Standards Of Medical Care In Diabetes-2016. The Journal of Applied
Research and Education. January 2016, Volume 39, Supplement 1.
http://care.diabetesjournals.org/content/suppl/2015/12/21/39.Supplement_1.DC2/2016-Standards-of-
Care .. Accessed May 4, 2018.
CONCLUDING THE VISIT CARE DISCUSSION
You and Dr. Clay return to the exam room to talk to Mr. Morales about your
recommendations for his diabetic care.
Dr. Clay starts, “We’d like you to stop taking the metformin and pioglitazone
because those medications are not the best or safest in patients who have heart
failure like you do.”
“But won’t that make my blood sugars go up with two less medicines everyday? I
thought we were going to get my blood sugars lower,” Mr. Morales wants to know.
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“You’re right, Mr. Morales. Without those two medicines, your readings will likely
increase, so we’d like to increase your glipizide to 10 mg daily to help. Taking
glipizide with glargine insulin every day will also help. We’d like to have you call the
office in a few days with your readings so we can see how it’s going. We will be
working closely in the coming weeks and months to keep your glucose well
controlled, and we’d like you to see a diabetes educator and a nutritionist for help
with your food choices and portions.”
You tell him that you’d like to better control his blood pressure, and he agrees to
take the increased lisinopril dose.
“The good thing, Mr. Morales, is that getting your glucose and blood pressure
under control will help your kidneys function better. And stopping smoking will
help too. Have you thought about whether you are ready to quit now? Would you
consider setting a quit date?”
He responds, “Maybe we can talk about that when I come back the next time.”
You remind him to check his blood sugar with his glucose meter when he feels
“low” so that he doesn’t eat when he doesn’t need to. You reiterate the proper
treatment of blood glucose to achieve a reading of >70 mg/dL (>3.9 mmol/L).
You make him an appointment for a dilated eye exam and advise him to check his
feet daily.
You are able to give him two more weeks of testing strips and the toll-free number
to the patient assistance line for glargine insulin so that he can request samples.
You ask him to see the clinic’s social worker for further help with patient
assistance and hand him a note for work explaining his need to be allowed off the
line to check his blood sugar regularly, as well as his need to be seen in close
follow up with Dr. Clay.
As he leaves, Mr. Morales says, “I’ll see you in two weeks, and thank you for taking
the time to really talk to me and find out how to help. I feel like I am really going to
be able to take care of myself this time, and I’ll have my tobacco quit date when I
see you again!”
See the associated reference ranges in conventional and SI units.
LAB RESULTS AND DIABETIC
NEPHROPATHY
MANAGEMENT
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It is two weeks later and Mr. Morales is back in Dr. Clay’s diabetes clinic.
You take a look at the electronic medical record, and the lab results from Mr.
Morales’ initial clinic visit reveal:
Lab Values: Conventional: SI:
Potassium 4.8 mEq/L 4.8 mmol/L
BUN 29 mg/dL 10.4 mmol/L
Creatinine 1.8 mg/dL 159 μmol/L
Hemoglobin A1c 8.3%
Total cholesterol 213 mg/dL 5.52 mmol/L
Triglycerides 385 mg/dL 4.35 mmol/L
HDL 38 mg/dL 0.98 mmol/L
LDL 117 mg/dL 3.03 mmol/L
Liver function panel: normal
Spot urine albumin to creatinine ratio: 120 mcg/mg creatinine
You realize that the spot urine albumin to creatinine ratio confirms Mr. Morales’
prior history of increased urinary albumin excretion. Prior to seeing Mr. Morales,
you decide to look up some information about diabetic nephropathy.
You are glad that you increased Mr. Morales’ lisinopril dose during the last visit
since it will hopefully slow progression of his diabetic nephropathy.
You highlight that his A1c is above goal, but you tell Dr. Clay that it may not be
necessary to make adjustments to his diabetic regimen since that was done at the
last visit.
See the associated reference ranges in conventional and SI units.
Diabetic Nephropathy
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Diabetic Nephropathy
EpidemiologyEpidemiology
Diabetic nephropathy occurs in 20% to 40% of diabetic patients and is the most
common etiology of end-stage renal disease in the U.S.
Risk factors associated with the progression of diabetic nephropathy include:
obesity, increasing age, African American race, and tobacco abuse.
PathogenesisPathogenesis
Kidney insult appears to originate with glomerular hypertension and
hyperfiltration. Chronic hyperglycemia leads to mesangial expansion,
deposition of matrix, increased amount of VEG-F and other cytokines, local
inflammation, and activation of protein kinase C.
Prevention / TreatmentPrevention / Treatment
Two large prospective trials (DCCT with type 1 diabetics and UKPDS with Type 2
diabetics) revealed that intensive glucose management resulted in prevention
or delayed onset and progression of diabetic nephropathy.
Aggressive blood pressure lowering is critical for treatment of increased urinary
albumin excretion. In patients with hypertension with increased urinary
albumin excretion, an ACE inhibitor or ARB therapy is recommended to delay
the onset and decrease progression of diabetic nephropathy.
ReferralReferral
Referral to nephrology is appropriate if the the cause of kidney disease is not
certain, and or there are challenging management issues present, such as
resistant hypertension or electrolyte derangement. The threshold for referral to
nephrology varies across providers; however, nephrology should be consulted if
Stage 4 or greater chronic kidney disease (GFR < 30 ml/min per 1.73 m )
develops since this has been found to reduce cost, improve quality of care, and
keep people off dialysis longer.
2
FOLLOW-UP VISIT CARE DISCUSSION
You and Dr. Clay congratulate Mr. Morales on his weight loss before tellingYou and Dr. Clay congratulate Mr. Morales on his weight loss before telling
him to return for a follow-up visit.him to return for a follow-up visit.
!
You and Dr. Clay review Mr. Morales’ vitals. His weight is down two pounds and his
blood pressure is 129/72 mmHg.
Mr. Morales greets you, “You are going to love these blood sugars! That ADA Web
site has great information and the social worker has gotten it worked out so that I
receive patient assistance for most of my medications and supplies. I’ve learned so
much from the nutritionist and diabetes educator. I’ve completely changed the
way I eat and I’m taking a walk around the block every evening before supper.
There is one thing, though. My wife does most of the grocery shopping and she
doesn’t speak English very well. Are there any resources available in Spanish?”
“Certainly, Mr. Morales – I’ll make sure that you have that information before you
leave.”
You both review Mr. Morales’ blood sugar log and find that by taking his glargine
insulin daily, his fasting readings have come into goal nicely and his prandial
readings are within goal >75% of the time.
“Congratulations on all your hard work, Mr. Morales! These readings look
wonderful and your weight and blood pressure are coming down nicely. I don’t
think I’ll make any changes to your diabetes regimen today, but keep calling every
week with your readings so that we can stay on top of your sugar control. You
know, if you keep losing weight, you may be able to come off the insulin.”
“Thanks, Dr. Clay. I’ve been working hard, and I sure would like to stop giving
myself that shot, so I’m going to keep on losing. And I’ve decided to quit smoking
next Monday.”
“That’s great, Mr. Morales! We’ll make sure that you get some printed information,
as well as some website addresses, so you can maximize your chances for success.
You review the remainder of Mr. Morales’ labs, including his HbA1c, renal function,
and the presence of microalbuminuria.
Dr. Clay tells Mr. Morales to return to the office in four weeks for a follow-up visit
and reminds him to stop at the lab to check on his potassium and kidney function
because of the higher ACE inhibitor dose.
“See you then, Dr. Clay. I’ll be calling with my readings in a week or two.”
Diabetes Patient Resources in Spanish
The ADA website has excellent resources for Spanish-speaking patients and
their families.
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Thank you for completing Internal Medicine 08: 55-year-old male with
chronic disease management.