A 55-year-old man presents to his primary care physician for a routine physical examination at his wife’s insistence. He has a medical history of benign prostatic hyperplasia and depression, but has refused medications previously. Intake vitals show a blood pressure of 148/92 mmHg, a heart rate of 78 beats per minute, and a respiratory rate of 12 breaths per minute.
He is counseled about lifestyle changes and scheduled to follow-up. His elevated blood pressure is confirmed at two more office visits, and screening examinations and tests do not indicate any end-organ damage.
What is the next step in managing his hypertension?
Begin an a-blocker. (A, C) The patient can now be diagnosed with hypertension, since his high blood pressure has been confirmed at three visits. Given that his blood pressure has remained high despite lifestyle changes, it is now appropriate to begin pharmacologic therapy. Achieving a specific blood pressure target is often more important than the specific agent selected; however, there are some reasons for choosing a specific agent. An α-blocker would have the benefit of reducing blood pressure while also treating his benign prostatic hyperplasia. Other diseases that benefit from selecting a specific antihypertensive agent include diabetes (ACE inhibitor, ARB), heart failure or post-MI (ACE inhibitor, ARB, β-blocker, aldosterone antagonist), atrial fibrillation (β-blocker, calcium channel blocker), essential tremor (β-blocker), Raynaud phenomenon (calcium channel blocker), osteoporosis (thiazide diuretic, which increases calcium reabsorption), and hyperthyroidism (β-blocker). (B) Starting therapy with two drugs is appropriate when the baseline blood pressure is >160/100 mmHg. (E) Starting a β-blocker would be unwise, given his history of depression. (F) The patient does not meet the definition of hypertensive urgency or emergency and does not need immediate blood pressure reduction.
A 55-year-old woman with known ulcerative colitis is admitted to the hospital for intractable diarrhea. She has had eight to ten episodes per day for the past 2 days, along with a fever of 39.1°C. She is typically on 5-ASA for maintenance, which is prescribed by her gastroenterologist in South America, where she is from. She has never had a colonoscopy. In the hospital, she fails to improve with IV methylprednisolone.
What is this patient’s contraindication for starting infliximab?
No documented PPD test. Severe ulcerative colitis flares are characterized by >6 bowel movements per day and systemic symptoms. If a severe flare has failed IV steroids, the next step would be an anti-TNFα agent such as infliximab. However, this drug carries the risk of reactivation TB and requires a documented negative PPD prior to use. (A, B) These are not contraindications to infliximab use. (E) A valid alternative in this case would be cyclosporine A, as additional treatment is required for this severe flare. (D) Infliximab has no correlation with colon cancer, although it does carry a slightly increased risk of lymphoma.
A 38-year-old woman presents to the office for a routine evaluation. She has no current complaints or current medical problems. However, she states that as a child she was ill with “aching joints” and “rashes on her arms” and was treated with “some antibiotic for a long time.” She is not on any medications and has no known allergies. On examination, her vitals are normal. On cardiovascular examination, she has a faint mid-diastolic murmur heard best at the apex. The rest of her examination is normal. She is scheduled to undergo a dental procedure next week.
What is the most appropriate step in management?
No prophylaxis needed. Prophylaxis for infective endocarditis is recommended only for patients at the highest risk of developing a serious complication if infective endocarditis were to occur. These include patients with prosthetic heart valves, a history of infective endocarditis, a cyanotic congenital cardiac disease that is unrepaired, or patients with heart transplants that also have valvular disease. (A, C) Appropriate prophylaxis for these patients would be oral amoxicillin 30 to 60 minutes prior to the procedure, or IV ampicillin for patients who cannot tolerate oral medications. This patient likely had rheumatic fever as a child and has mild mitral stenosis as a result; however, this is not an indication for antibiotic prophylaxis before dental procedures.
An 83-year-old man with a history of hypertension, diabetes, and prostate cancer presents to the Emergency Department complaining of 4 days of back pain worsened with coughing. Associated symptoms include lower-extremity numbness. On further questioning, the patient reveals three episodes of urinary incontinence and one episode of losing bowel control. Physical examination is notable for hyper-reflexia of the lower extremities and decreased sphincter tone.
Where is the most likely lesion in this patient?
Lumbar spine. Spinal cord compression is a neurologic emergency. The most common site of bony metastasis in prostate cancer is the spine, and the lumbar spine is most frequently affected. Patients can present with back pain, bowel/bladder incontinence, erectile dysfunction, saddle anesthesia, lower-extremity sensory deficits and weakness, and upper motor neuron signs below the lesion. MRI is the diagnostic test of choice. High-dose dexamethasone should be started immediately, but many patients ultimately require surgical decompression.
A 44-year-old man presents for a routine health maintenance visit. He has no past medical history. He smokes half a pack of cigarettes daily and does not consume alcohol. His diet consists of fast food on a regular basis. His mother has diabetes and his father has high cholesterol. The patient has a heart rate of 72 beats per minute and a blood pressure of 138/74 mmHg. He has a BMI of 32 kg/m2 . Laboratory results are shown below.
A repeat fasting glucose 2 weeks later shows a glucose of 134 mg/dL.
Aside from starting the patient on metformin, what is the most appropriate next step in management?
Oral atorvastatin. Guidelines for initiating lipid-lowering therapy with a statin include those with clinically significant atherosclerotic disease (including myocardial infarction, stroke, coronary revascularization), LDL >190 mg/dL, diabetics between the ages of 40 to 75, and those with a 10-year risk of cardiovascular disease >7.5% (ACC/AHA opinion). This patient has two fasting blood glucose levels ≥126 mg/dL, making the diagnosis of diabetes. As such, he should begin a statin along with medications to control his blood glucose.
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