This morning we went through a case where a patient presented to clinic to establish care and was found to have an elevated blood pressure in the office. With the help of our awesome primary care expert discussant, Dr. Joseph Diaz, we reviewed initial evaluation in patients with suspected hypertension. We discussed the importance of confirming diagnosis with home blood pressures or ambulatory monitoring.
We also reviewed initial physical exam and work up once diagnosis is made. This includes listening for abdominal bruit, cardiac exam, thyroid, and considering fundoscopic exam if concerned HTN is long-term or malignant. The goal of labs and studies are to determine if there is evidence of end organ damage and to characterize the patient’s overall cardiovascular risk profile.
Lastly we discussed treatment including specific lifestyle modifications that have been proven to help lower blood pressure. We reviewed options for monotherapy initiation and in small groups went over additional benefits, side effects, and contraindications for ACE, ARB, CCB, and thiazides.
Today we went through a outpatient case of a pregnant woman who comes to her primary care clinic for follow-up to acid reflux. She was thankfully doing fine but when we examined her we noticed that on her vitals she had an elevated BP, tachycardia, tachypnea, a systolic murmur and pedal edema. Should we be alarmed? Should we send her to the hospital?
We next revisited normal physiological changes to expect during pregnancy and ultimately concluded that we should be concerned about her elevated blood pressure but the rest of the physical exam findings are were normal for pregnancy. We then spend the next part of session going over the diagnostic criteria and findings for chronic hypertension, pre-eclampsia/eclampsia and gestational hypertension and the treatment option a. Our teams did a great job filling out the information and teaching each other. We were also fortunate to have our outstanding Family Medicine attending, Dr. Julie Celebi join us today to give us some expert insight regarding what she does in her practice.
Thank you for your clinical pearls, Dr. Celebi!
Janet also shared a fascinating, and very relevant, recent study that indicates that there is increased risk of developing AS and MR later in life if women experience a hypertensive disorder during pregnancy: https://www.acc.org/latest-in-cardiology/articles/2019/11/09/08/42/nov11-5am-hypertensive-disorders-of-pregnancy-aha-2019.
- Blood pressure should decrease as SVR decreases normally in pregnancy during the first trimester and then returning to prior baseline during the 2nd trimester. Elevated BP is therefore abnormal and should be concerning.
- If BP is elevated prior to 20 weeks, it is likely chronic hypertension. if is elevated after 20 weeks without any lab abnormalities, it is gestational hypertension. With proteinuria, after 20 weeks, we are concerned for pre-eclampsia.
- The current guidelines recommend treatment for SBPs >160, DBP >110, but for mild to moderate cases (between 140-150s/90-100s), treatment depends on patients’ co-morbidities and symptoms. First line treatment options are: PO nifedipine, IV labetalol or alpha-methyldopa. Attempt to deliver if this is a safe option for women experiencing pre-eclampsia/eclampsia.
Today at Hillcrest, we discussed a case of a clinic patient initially presenting with heartburn, suggestive of GERD. We then followed his course over a few years to the point where he started to have nocturnal symptoms despite adequate therapy, which prompted a referral to GI for an EGD. His EGD resulted in the discovery of an esophageal adenocarcinoma, for which he ultimately underwent an esophagogastrectomy with adjuvant chemotherapy. We used this case to build a discussion about many important aspects of GERD and the potential sequelae , highlighted below!
Take Home Points:
- GERD is a clinical diagnosis and it is appropriate to treat empirically with an 8 week trial of PPI in the absence of alarm symptoms. Always address lifestyle modification as well!
- Once symptoms are controlled, efforts should be made at least annually to deescalate PPI therapy as tolerable.
- Alarm features (constitutional symptoms, dysphagia, hematemesis/melena/unexplained anemia, or recalcitrant symptoms) can develop later in the disease course, so be thoughtful in follow-up as an EGD may be warranted when initially it was not indicated.
Today at the VA, we started off a series of outpatient focused cases by discussing a patient in his 50’s who presented with 1 year history of diarrhea and 70 lbs of weight loss. The teams collectively discussed their approach to diarrhea and an overall schema for the outpatient setting. We discussed the alarm features for diarrhea and, for our patient, the need for urgent colonoscopy. With a history of alcohol use disorder, CT findings of chronic pancreatitis, and an abnormal fecal elastase, the teams astutely diagnosed our patient’s diarrhea as malabsorption secondary to exocrine pancreatic insufficiency (EPI).
This morning’s Owen conference at UCSD covered PREP therapy for HIV prevention. A young adult male presented to primary care clinic, completed appropriate screening labs (see below), and started Truvada. For a great overview of recent guidelines, the CDC 2017 PREP guidelines are a great place to start! Many thanks to Dr. Kadakia and Shaun Giancaterino for putting together a great case discussion
In the midst of an epidemic of opioid misuse and overdose deaths, it’s valuable for all clinical staff to be aware of an effective treatment for this large public health problem. Who: Any MD’s, DO’s, PA’s or NP’s. Residents can take this course prior to obtaining their own DEA – your completion will be recorded for use later. What: AAAP Buprenorphine Half and Half Course (1/2 online and 1/2 in person) Where: MET Building, Room 223 When: May 29th, 12:30-4:45 pm Why: To be qualified to get a DEA waiver to prescribe buprenorphine AND to feel confident managing this growing patient population Interested? Block your calendars and RSVP to Carla Marienfeld at firstname.lastname@example.org Details: The in person portion is ½ of the 8 hour requirement. The remaining ½ must be done on line, and you must pass a self-study exam to apply for the waiver.