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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2892_Библиотеки_им_академика_М_И_Перельмана
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330 CASE FILES: FAMILY MEDICINE
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29.2 A 15-year-old girl presents to your office with her mother for a preparticipation sports physical. She would also like to discuss the addition of birth
control. When her mother leaves the room, you learn that the girl is not sexually active but wants to start oral contraceptives because she heard they help
improve acne. She does not smoke, drink alcohol, or use illicit drugs; is in
honors classes in ninth grade; and plays on the junior varsity softball team.
Vital signs are within normal limits, and she has a body mass index (BMI) in
the 97th percentile for her age. Physical examination is unremarkable. Which
of the following should be performed at this time?
A. Perform routine Papanicolaou (Pap) smear before offering contraception
B. Periodic screening for drug use with a urine drug toxicology test
C. Cholesterol testing
D. Refer to obesity clinic or weight loss program
29.3 A mother brings her 12-year-old child to the clinic for a routine health maintenance examination. She mentions that the child, who was assigned male
gender at birth, has shown interest in presenting in a traditionally feminine
fashion, including wearing makeup and dresses. The child recently asked to
be referred to as “she” and to go by a female name. The mother requests guidance on how to respond. Which of the following is the best response?
A. Advise the mother that gender exploration is common in adolescence,
but that it is usually a self-limited phase that will resolve spontaneously.
B. Advise the mother that gender exploration is common in adolescence,
but that it is important to affirm the child’s gender identity with the cor-
rect name and pronouns and respect their gender expression.
C. Refer the patient to a psychiatrist for evaluation of mental illness.
D. Encourage the mother to use male pronouns and encourage traditionally
masculine activities such as sports.
ANSWERS
29.1 B. This answer choice is a 16-year-old female adolescent student with a diastolic murmur. Any patient with a diastolic murmur, grade 3/6 or louder
systolic murmur, murmur suggestive of HCM, or signs of Marfan syndrome
should be evaluated by a cardiologist prior to clearance to participate in athletics. The murmur of HCM typically gets louder with maneuvers that reduce
preload, such as the Valsalva maneuver or when standing. The patients in
answers A and C have systolic murmurs, but these murmurs were both 2/6
and did not meet the threshold of 3/6 for referral to a cardiologist.
29.2 D. Per the USPSTF, BMI should be calculated annually for adolescent
patients. If BMI is greater than the 95th percentile, it is recommended to
refer patients to a weight loss program or obesity clinic. Further counseling by
the provider on dietary advice and physical activity should also be done at this
time. Pap smears for cervical cancer screening (answer A) are recommended
to start at age 21 regardless of sexual activity and are not indicated for this
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patient, who is 16. Lipid screening (answer C) should be targeted to those
who are at high risk based on personal or family history; while obesity is a
risk factor for hyperlipidemia, there is not consensus regarding cholesterol
screening in the absence of other risk factors. Routine toxicology screening
(answer B) in adolescents is not recommended.
29.3 B. An affirming approach is important for the transgender adolescent, who
is at risk of social stigma and for whom supportive family structures are predictive of better health outcomes. While gender exploration is common in
childhood and adolescence, patients’ gender identities should be treated as
real and not questioned or refuted (answer D). While psychiatry referral is
often required prior to initiation of hormone therapy or gender-affirming
surgery, it should not be communicated to the parent or child that the child
has a mental illness (answer C). A referral to psychiatry is, however, warranted if the child manifests signs of anxiety, depression, or suicidal ideation.
Answer A (advise that gender exploration is common in adolescence but is
usually self-limited and will resolve spontaneously) is not necessarily accurate
and should not be communicated; by the time adolescence is reached, playtime and imagination are less common.
CLINICAL PEARLS
» Adolescents may see health care providers irregularly. Take the time at
each visit to ensure that age-appropriate provisions of screening are up
to date.
» Review the immunization history and current guidelines with each ado-
lescent at every visit, ensuring adequate opportunity for education and
shared decision-making.
» True contraindications to participation in sports are rare. Almost every-
one should be able to participate in some form of athletic activity.
» Providers should ask adolescents about preferred pronouns (ie, she/he/
they) as well as preferred names, and these should be documented in the
medical record for future encounters.
» All adolescents and their parents should be asked about personal his-
tory of exertional chest pain, dyspnea, syncope, and heart murmurs, and
about family history of HCM.
REFERENCES
American Medical Association. Guidelines for Adolescent Preventive Services (GAPS): Recommendations
Monograph. Chicago, IL: American Medical Association; 1997.
Centers for Disease Control and Prevention. FDA licensure of quadrivalent human papillomavirus
vaccine (HPV4, Gardasil) for use in males and guidance from the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2010;59(20):630-632.
332 CASE FILES: FAMILY MEDICINE
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Centers for Disease Control and Prevention. Prevention and control of meningococcal disease: recom-
mendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal
Wkly Rep. 2013;62(RR-02):1-22.
Centers for Disease Control and Prevention. Vaccines and immunizations. http://www.cdc.gov/
vaccines/. Accessed January 8, 2019.
Crissman HP, Berger MB, Graham LF, Dalton VK. Transgender demographics: a household probability
sample of US adults, 2014. Am J Pub Hlth. 2017;107(2):213-215.
Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants,
Children, and Adolescents [pocket guide]. 4th ed. Elk Grove Village, IL: American Academy of
Pediatrics; 2017.
Ham P, Allen C. Adolescent health screening and counseling. Am Fam Physician. 2012;86(12):1109-1116.
Mirabelli MH, Devine MJ, Singh J, Mendoza M. The pre-participation sports evaluation. Am Fam
Physician. 2015;92(5):371-376.
Olson J, Forbes C, Belzer M. Management of the transgender adolescent. Arch Pediatr Adolesc Med.
2011;165(2):171-176.
United States Preventive Services Task Force. Chlamydia and Gonorrhea Screening. https://www
.uspreventiveservicestaskforce.org/uspstf/recommendation/chlamydia-and-gonorrhea-screening.
Accessed May 15, 2020.
CASE 30
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A 47-year-old African American man presents to your office for a follow-up visit.
He was seen 3 weeks ago for an upper respiratory infection and noted incidentally
to have a blood pressure (BP) of 164/98 mm Hg. He vaguely remembers being told
in the past that his BP was “borderline.” He feels fine and has no complaints, and his
review of systems is entirely negative. He does not smoke cigarettes, drinks “a few
beers on the weekends,” and does not exercise regularly. He has a sedentary job.
His father died of a stroke at the age of 79 years. His mother is alive and in good
health at the age of 72 years. He has two siblings and is not aware of any chronic
medical issues that they have. In the office today, his BP is 156/96 mm Hg in his
left arm and 152/98 mm Hg in the right arm. He is afebrile, his pulse is 78 beats/
min, and his respiratory rate is 14 breaths/min. He is 70 inches tall and weighs 210
lb (body mass index [BMI] 30.1 kg/m2). A general physical examination is normal.
▶ What diagnosis (or diagnoses) can you make today?
▶ What further evaluation needs to be performed?
▶ What nonpharmacologic intervention(s) may be beneficial?
▶ What is the recommended initial medication management?
334 CASE FILES: FAMILY MEDICINE
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ANSWERS TO CASE 30:
Hypertension
Summary: A 47-year-old African American man presents with
An elevated BP reading when seen for an unrelated problem visit and another elevated
BP on a follow-up visit
Obesity and a sedentary lifestyle but no other high risks based on his personal or
family history
No history of smoking and statement that he drinks “a couple of beers on the
weekends”
Normal general examination
Diagnoses: Hypertension and obesity.
Necessary further evaluation: Blood glucose; serum potassium, fasting cholesterol
panel, estimated glomerular filtration rate (GFR), creatinine, and calcium levels;
hematocrit; urinalysis; electrocardiogram (ECG).
Nonpharmacologic interventions: DASH (Dietary Approaches to Stop Hypertension) diet; alcohol limitation to no more than two drinks per day; increased physical activity; weight reduction.
Recommended initial medication: Thiazide diuretic or calcium channel blocker.
ANALYSIS
Objectives
1. State the diagnostic criteria for hypertension. (EPA 1, 2, 3)
2. Be able to state the recommended initial evaluation of persons found with an
elevated BP. (EPA 3)
3. State the medication and lifestyle modifications that can help to control BP.
(EPA 4)
4. Be able to report the complications and risks of uncontrolled hypertension.
(EPA 10, 12)
Considerations
The patient presented here is typical of one seen every day in primary care offices
and represents the most common presentation of hypertension. Most hypertensive
patients do not have any symptoms of their disease. They are typically seen for
another reason and noted to have a high BP reading. Untreated hypertension significantly raises an individual’s risk of myocardial infarction, cerebrovascular accident, and renal failure, among other conditions. The risk of cardiovascular disease
doubles with each increase in BP of 20/10 mm Hg above 115/75 mm Hg. Because of
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the high prevalence of the problem, the lack of symptoms, and the demonstrated
efficacy of treatment in reducing the risk of complications, the United States
Preventive Services Task Force recommends screening adults aged 18 and older for
hypertension by measuring their BP. For patients aged 18 to 39 without increased
risk, the interval for screening is every 3 to 5 years. The recommended screening
is annually in low-risk patients age 40 and older and for all adults with increased
risk for hypertension, such as high normal (> 130/85 mm Hg) BP measures and
in overweight/obese patients. Most practitioners will check the BP of every adult
patient at every office visit.
APPROACH TO:
Hypertension
DEFINITIONS
AMERICAN HEART ASSOCIATION/AMERICAN COLLEGE OF CARDIOLOGY (AHA/ACC) CONSENSUS STATEMENT: 2018 guidelines that
recommend pharmacologic BP management based on 10-year risk estimates, such
as the atherosclerotic cardiovascular disease (ASCVD) risk calculator (see Case 35).
JNC 8: The eighth report of the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood Pressure. A comprehensive,
evidence-based review of the diagnosis, evaluation, and management of hypertension published in 2013.
CLINICAL APPROACH
Epidemiology
Hypertension is the most common primary diagnosis at office visits in the
United States. Approximately 32% to 46% of American adults have hypertension,
with 30% being unaware of the problem. The prevalence is higher in African
Americans and in older patients. National Health and Nutritional Examination
Surveys (NHANES) data suggest that hypertension is responsible for approximately one-third of heart attacks, one-half of heart failure, and one-fourth of
premature deaths. Most patients with end-stage kidney disease are hypertensive.
Hypertensive nephrosclerosis is responsible for approximately one-fourth of
end-stage kidney disease. The risk of complications is directly related to the elevation
of the BP—the higher the BP, the higher the risk.
Pathophysiology
The diagnosis of hypertension relies on accurate measurement of BP. The appropriate technique is to allow the patient to sit quietly in a chair (not on the examination
table) with a supported back and feet on the floor for 5 minutes prior to making the
measurement. Allowing patients to empty their bladder prior to BP measurement
can also reduce the chance of a falsely elevated reading. The BP should be measured
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at least twice, using a calibrated sphygmomanometer and an appropriate size cuff
for the patient. The BP cuff should encircle at least 80% of the patient’s arm; a cuff
that is too small can result in a falsely elevated reading. The diagnosis of hypertension is made based on the average of two properly taken BP measurements at two
or more office visits.
Evaluation. When hypertension is diagnosed, an evaluation consisting of a history, physical examination, and focused diagnostic studies should be performed,
with the goals of assessing overall cardiovascular risks, identifying possible secondary causes of hypertension, and determining the presence of any end-organ damage.
Secondary causes should be considered, especially in patients with difficult-tocontrol BP. The most common secondary causes include obstructive sleep apnea,
hyperaldosterone states, drugs (recreational, prescription, or over-the-counter like
caffeine and nonsteroidal anti-inflammatory drugs), and renovascular or renal disease. Less common secondary causes include coarctation of the aorta, Cushing disease, hyperthyroidism, hyperparathyroidism, and pheochromocytoma. Historical
information should include personal and family medical histories, an assessment of
diet and activity levels, and specific questioning regarding tobacco, alcohol, recreational drug, and medication (both prescription and nonprescription) use. Patients
should be questioned about cardiovascular, cerebrovascular, and peripheral arterial
disease symptoms.
Physical Examination. Along with BP in both arms, examination should include
all other vital signs and a measurement of BMI. Other specific components of the
examination should include a fundoscopic examination for signs of retinopathy;
oropharynx and neck for signs of obstructive sleep apnea; palpation of the thyroid;
auscultation for carotid, femoral, and renal bruits; palpation of peripheral pulses;
abdominal palpation for signs of organomegaly or aortic aneurysm; and a complete
cardiopulmonary examination.
Te st i n g. Initial testing should include measurement of serum potassium, creatinine (with GFR calculation), calcium, blood glucose, fasting lipids, and hematocrit.
A urinalysis should be done to look for proteinuria or cellular components suggestive of renal disease. An ECG should be performed to evaluate for changes consistent with coronary artery disease and to screen for left ventricular hypertrophy.
Treatment
Elevated systolic BP is a greater risk for cardiovascular disease complications than
elevated diastolic pressure. Control of systolic BP tends to be more difficult to
achieve, and when it is achieved, the diastolic BP usually comes under control
as well. JNC 8, the American College of Physicians, and the American Academy
of Family Physicians recommend the goal of treatment of lowering the BP to less
than 140/90 mm Hg in adults up to age 59 and 150/90 mm Hg in patients age 60
and above. For persons with diabetes or kidney disease, the goal is to achieve a BP
of less than 140/90 mm Hg. The AHA/ACC consensus statement’s recommendations are for target BPs of less than 130/80 mm Hg.
Nonpharmacologic Management. Once the diagnosis of hypertension is made,
patients should be advised of specific lifestyle modifications that can both reduce
their BP and reduce their overall cardiac risk factors. These should include efforts
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to lose weight if overweight or obese, increase physical activity, and reduce consumption of alcohol. Men should consume no more than two alcoholic beverages
a day and women no more than one. Any smoker should be counseled to quit.
ADASH diet that is rich in potassium, calcium, magnesium, fiber, and protein; low
in saturated and trans fats; and lower in sodium reduces BP in an amount comparable to single-agent drug therapy. An informational brochure detailing the DASH
diet is available from the National Heart, Lung, and Blood Institute. Combining the
various lifestyle modifications provides additive benefits, and these efforts should
continue even when the decision is made to start medications.
Pharmacologic Management. Lowering BP reduces the risk of adverse outcomes
such as strokes and heart attacks. In the primary treatment of hypertension in
African American patients, thiazide diuretics or calcium channel blockers are the
recommended first-line therapy. In non–African American patients, according to
the JNC 8, the first-line pharmacologic treatment can be diuretics, calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors, or angiotensin
receptor blockers (ARBs), with a goal of < 140/90 mm Hg in those under age 60
and < 150/90 mm Hg if age 60 or older. Patients with hypertension that is inadequately controlled with nonpharmacologic interventions alone should be started
on the agents described unless there is a compelling reason to start another class of
medication (Table 30–1). The goal of therapy is to attain and maintain goal BP. If
goal BP is not reached with one agent after 1 month, then the provider can either
increase the dose of the initial agent or add a second drug.
Table 30–1 • JNC 8 RECOMMENDATIONS FOR STARTING SPECIFIC
CLASSES OF ANTIHYPERTENSIVE MEDICATION
Indication Class of Medication
Black patients Calcium channel blocker
Nonblack patients younger than
60years
Nonblack patients 60 years or older Calcium channel blocker
Patients with chronic kidney disease Angiotensin-converting enzyme inhibitor
Patints with history of coronary artery
disease
Thiazide diuretic
Angiotensin-converting enzyme inhibitor
Angiotensin receptor blocker
Thiazide diuretics
Calcium channel blockers
Thiazide diuretic
Angiotensin-converting enzyme inhibitor
Angiotensin receptor blocker
Angiotensin receptor blocker initial or add on for goal
of blood pressure < 140/90 mm Hg
Beta-blocker (especially if reduced systolic function)
Angiotensin-converting enzyme inhibitor
Angiotensin receptor blocker
(Continued)
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Table 30–1 • JNC 8 RECOMMENDATIONS FOR STARTING SPECIFIC
CLASSES OF ANTIHYPERTENSIVE MEDICATION
Indication Class of Medication
Patients with diabetes mellitus without
kidney disease
Patients with heart failure Angiotensin-converting enzyme inhibitor
Prevention of recurrent cerebrovascular
accident
Nonblack: Angiotensin-converting enzyme inhibitor
Angiotensin receptor blocker
Thiazide diuretic
Calcium channel blocker patients
Black: Thiazide diuretics
Calcium channel blockers
Angiotensin receptor blocker
Beta-blocker
Spironolactone
Angiotensin-converting enzyme inhibitor
Angiotensin receptor blocker
Calcium channel blockers
Thiazide diuretics
(continued)
CASE CORRELATION
See also Case 33 (Obesity) and Case 35 (Hyperlipidemia).
COMPREHENSION QUESTIONS
30.1 A 62-year-old woman presents for a routine physical examination. She
is asymptomatic and is not taking any medications. Her BP is found to be
145/85 mm Hg on two readings, and her BMI is 29 kg/m2. Review of her
chart reveals that her BP was 143/84 mm Hg on a visit 4 months ago for a
urinary tract infection. Which of the following is the most accurate statement
regarding her BP?
A. Her BP is normal, and she is at average risk for developing hypertension.
B. She is at risk for needing pharmacologic treatment for hypertension.
C. She has hypertension and should be started on a thiazide diuretic.
D. She has hypertension and should be started on multidrug therapy.
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30.2 A 66-year-old Caucasian woman has an average BP of 155/70 mm Hg
despite appropriate lifestyle modification efforts. Her only other medical
problems are osteopenia, kidney stones, and mild depression. Her last lipid
panel revealed a total cholesterol of 160 mg/dL, high-density lipoprotein of
40 mg/dL, and low-density lipoprotein of 90 mg/dL. Which of the following
would be the most appropriate treatment at this time?
A. Lisinopril (Prinivil, Zestril)
B. Propranolol (Inderal)
C. Amlodipine (Norvasc)
D. Chlorthalidone
E. Losartan (Cozaar)
30.3 A 48-year-old Caucasian man with type 2 diabetes has had persistent BP
readings of 150/95 mm Hg for the past 6 months. Current medications
include glyburide and metformin. His last hemoglobin A1c was 7.9%, and the
patient has a BMI of 24 kg/m2. On physical examination, position sense is
intact but a peripheral neuropathy is detected in a stocking-and-glove pattern. Vibratory sensation is decreased bilaterally on both lower extremities.
Eye examination shows mild papilledema but no cotton wool spots. When
questioned, he says that he still occasionally sneaks a cookie after dinner and
drinks alcohol nightly. Which of the following is the most appropriate treatment for him?
A. DASH diet and recheck BP in 3 months
B. Thiazide diuretic alone
C. ACE inhibitor alone
D. Combination of ACE inhibitor and thiazide diuretic
30.4 At a routine checkup, a 6-year-old boy is found to have a BP of 150/90 mm Hg.
Repeated BP readings are consistently elevated. The child was delivered at
36 weeks by normal spontaneous vaginal delivery with no complications. All
major milestones were met on time, and he currently is enrolled in first grade.
The child has been healthy up until this point. Which of the following are the
most appropriate diagnosis and therapeutic step?
A. The child has essential hypertension and should be started on the
DASH diet.
B. The child most likely has hyperthyroidism, should be started on a
beta-blocker, and should have thyroid studies performed.
C. The child most likely has renal parenchymal disease and should have a
urinalysis and renal ultrasound ordered.
D. The child most likely has “white coat” hypertension; follow up in
3months if there is no family history of hypertension.
E. The child most likely has a pheochromocytoma and should start a
24-hour urine collection for metanephrines.
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