A 58-year-old man who smokes cigarettes has a history of hypertension and asks about reducing his risk for myocardial infarction. A lipid profile shows low HDL cholesterol at 32 mg/dL.
Which of the following is an important recommendation in attempting to raise the HDL?
(NCEP, http://www.nhlbi.nih.gov/guidelines/cholesterol.) Within this group of choices, only exercise and smoking cessation have been shown to raise HDL. A low-cholesterol diet actually lowers HDL. Among current lipid-lowering medications, nicotinic acid has the most potent HDL-increasing effect at 15% to 35%, followed by fibric acids and then statins. Alcohol also increases the HDL level (HDL2 and HDL3 subfractions), thereby imparting some cardioprotective effect, but at the risk of cardiomyopathy, sudden death, hemorrhagic stroke, and other noncardiovascular problems among heavy drinkers. The cardiovascular system may benefit from aspirin (because of antiplatelet effects), but it has no effect on HDL. After initial enthusiasm for vitamin E, more recent studies have not shown consistent cardiovascular benefit from antioxidant vitamins. None of these raise HDL. DHEA supplements lower HDL values.
You are the primary care physician for a 78-year-old man with severe dementia, coronary artery disease, COPD, hyperlipidemia, and HTN. He takes hydrochlorothiazide, lisinopril, metoprolol, aspirin, simvastatin, and tiotropium as well as oxygen at 2 L/minute. The patient no longer recognizes his wife or other family members and requires total care at a nursing home facility. The wife approaches you stating that her husband never wanted to live like this and asks you to stop all of his medications including the oxygen and enroll him in hospice for comfort care. The patient’s living will states that his wife is to make decisions if he becomes incapacitated. The patient’s two grown children object to this plan and ask you to continue all current medications.
What is the appropriate next step?
The patient has a valid living will in place that clearly states the wife should make decisions when the patient becomes incapacitated. This living will must be honored. You could do your best to explain to the children why their mother’s decision is not only legally acceptable but ethically acceptable as well. Their father had expressed his wishes, and his current poor quality of life was not something he had wanted to prolong. You could emphasize that no action will be taken to hasten their father’s death and that he will be provided compassionate care until the day he dies naturally. Consulting an ethics committee can be helpful when documentation of the patient’s wishes is unclear. Serving as an advocate for the patient, even when the patient has lost decision-making capacity, is an essential role of the primary care physician. Withdrawal from care in this circumstance is unethical.
A 42-year-old banker sees you as a new patient. He states that he is healthy and takes no regular medications. His examination is normal except for a blood pressure of 150/94. When questioning him about alcohol use, he admits that he goes out drinking with friends about two Saturdays each month to relieve stress. At these times he will often have 8 to 10 mixed alcohol drinks. He and his wife have recently had several arguments about this habit, and she has threatened to divorce him if he doesn’t change his ways. Despite this, he has been unable to change. On one occasion he was arrested for driving while intoxicated. Nonetheless, he has continued to be successfully employed, has never been hospitalized for an alcohol-related problem, and has never had symptoms of alcohol withdrawal.
Which of the following statements is true regarding treatment of this patient?
This patient has an alcohol use disorder, which is defined as a maladaptive pattern of alcohol use causing clinically significant impairment or distress. Men who consume more than 14 drinks per week or 4 drinks on any one day, and women who consume more than 7 drinks per week or more than 3 drinks on any one day are at risk for this disorder. This patient has had significant marital discord, has been unable to cease alcohol use, and has had an arrest for driving while intoxicated. All of these indicate that the patient has clinically significant impairment from alcohol abuse. Alcohol use disorder may or may not be accompanied by alcohol dependence, which is characterized by symptoms and signs of alcohol withdrawal during periods of abstinence. Patients with alcohol use disorder are usually unable to limit the amount of alcohol that they consume, and therefore complete abstinence from alcohol is recommended. Mutual help groups (such as Alcoholics Anonymous) as well as medications (such as acamprosate and naltrexone) can be helpful in maintaining abstinence. Physician advice alone is usually unsuccessful. Alcohol use disorder is frequently accompanied by other psychiatric disorders such as depression. Alcohol use disorder can aggravate hypertension; blood pressure will improve with abstinence. Current understanding of alcohol use disorder suggests that there is a genetic tendency to this illness.
A 32-year-old stockbroker sees you because she has felt anxious almost every day for the past 9 months. She feels “keyed up” at work. At times she has difficulty concentrating and has made several minor errors in clients’ accounts. For the past year she has frequently had trouble falling asleep at night despite the fact that she always feels tired. She does not fall asleep during the day at inopportune times. She denies substance or alcohol abuse. Her vital signs and physical examination are normal. CBC, TSH, and chemistry panel are normal.
What is the most appropriate initial treatment alternative?
This patient meets criteria for generalized anxiety disorder (GAD). In general, a combination of pharmacologic and psychotherapeutic interventions is most effective for generalized anxiety disorder. The best agent for a patient with daily symptoms is a SSRI. SSRIs are safe and effective. Nausea and sexual impairment (anorgasmia in women, erectile dysfunction in men) are common side effects; patients may be unwilling to volunteer sexual side effects unless specifically questioned. Initial worsening of anxiety symptoms may occur; so starting doses are half of those used for treatment of depression. Short-acting benzodiazepines are often used on an “as-needed” basis. Longer-acting benzodiazepines tend to accumulate active metabolites and cause sedation with impairment of cognition and hence are not the first choice. Dependence is a serious problem when any benzodiazepine is used for more than a few weeks on ascheduled basis. Second-line agents for GAD include serotonin-norepinephrine reuptake inhibitors (SNRIs), buspirone, and anticonvulsants with GABAergic properties such as pregabalin. Atypical antipsychotic agents would not be used for GAD though they are effective for agitation in patients with bipolar disorder. Clonidine is a centrally acting antihypertensive that has not been shown to be effective for GAD. Tricyclic antidepressants have been relegated to third-line status because of side effects and toxicity.
A 25-year-old PhD candidate recently traveled to Central America for 1 month to gain information regarding the socioeconomics of that region. While there, he took ciprofloxacin twice a day for 5 days for diarrhea. However, over the 2 to 3 weeks since coming home, he has continued to have occasional loose stools plus vague abdominal discomfort and bloating. There has been no rectal bleeding.
Which of the following therapies is most likely to relieve this traveler’s diarrhea?
Patients with symptomatic Giardia lamblia infection typically present with several weeks of bloating, loose stools, and weight loss. Most patients respond to metronidazole therapy. This parasite is contracted by ingesting contaminated food or water, with the classic zoonotic reservoirs being the freshwater streams of the northern United States and also the water supplies in Russia and developing countries. Bacterial pathogens such as Campylobacter jejuni, enterotoxigenic Escherichia coli, Salmonella, and Shigella usually cause acute diarrhea, often bloody. They usually respond to fluoroquinolones or azithromycin. Many bacterial pathogens in developing countries are resistant to trimethoprim-sulfamethoxazole. Oral glucose-electrolyte solution rehydration is the mainstay of Vibrio cholerae therapy. Hydration rather than antibiotics is also the key for enterohemorrhagic E coli.
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