Transcript hypertension

COMMON DISEASES IN FAMILY PRACTICE
Department of Family and Community Medicine
University of the Philippines-Philippine General Hospital
COMMON DISEASES
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DYSPEPSIA
URINARY TRACT INFECTION
HYPERTENSION
BRONCHIAL ASTHMA
PULMONARY TUBERCULOSIS
DIABETES MELLITUS
DYSPEPSIA
DYSPEPSIA
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bloatedness, fullness, gnawing or burning
epigastric area
continously or intermittently
more than 2 weeks
chronic or recurrent
associated with : anorexia, early satiety,
belching, nausea, regurgitation, vomiting
with or without alarm symptoms/signs
Dyspepsia: alarm features
1. age at onset >45
2. weight loss
3. anemia
4. hematemesis
5. melena
6. hematochezia
7. dysphagia
8. odynophagia
9. persistent vomiting
10. abdominal mass
11. jaundice
12. chronic NSAID intake
13. chronic alcohol intake
14. previous history of ulcer
DYSPEPSIA
Pharmacologic Treatment:
2-4 wks PPI
Non-Pharmacologic Advice:
avoid alcohol, milk, tea, carbonated drinks, coffee,
acidic beverages, small frequent feedings, avoid
skipping meals
WOF: increased abdominal pain, alarm symptoms,
absence of improvement after >7days of
tx
Proton pump inhibitors
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Esomeprazole 20 and 40mg OD
Omeprazole 20 and 40mg OD
Rabeprazole 20mg OD
Pantoprazole 40mg OD
Lansoprazole 15 and 30 mg OD
URINARY TRACT INFECTION
URINARY TRACT INFECTION
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ACUTE UNCOMPLICATED CYSTITIS IN WOMEN
ACUTE UNCOMPLICATED PYELONEPHRITIS IN WOMEN
ASYMPTOMATIC BACTERIURIA IN ADULTS
UTI IN PREGNANCY
RECURRENT UTI IN WOMEN
COMPLICATED UTI
UTI IN MALES
The Philippine Clinical Guidelines on the Diagnosis and Management of Urinary Tract Infections
in Adults 2004
ACUTE UNCOMPLICATED CYSTITIS IN WOMEN
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Dysuria, frequency or gross hematuria, with or
without backpain
Without symptoms of vaginitis, pyelonephritis, risk
factors for subacute pyelonephritis or complicated UTI
>100 CFU/mL; ≥5 wbc/hpf
Standard urine microscopy is not a prerequisite for
treatment
Pre-treatment urine culture and sensitivity is not
recommended
ACUTE UNCOMPLICATED CYSTITIS IN WOMEN
DRUG
DOSAGE
DURATION
TMP-SMX
800/160 mg BID
3 days
NORFLOXACIN
400 mg BID
3 days
OFLOXACIN
200 mg BID
3 days
CIPROFLOXACIN
250 mg BID
3 days
LEVOFLOXACIN
250 mg OD
3 days
ACUTE UNCOMPLICATED PYELONEPHRITIS
IN WOMEN
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fever (>38C), chills, flank pain, CVA tenderness,
nausea, vomiting ±lower UTI symptoms
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>10,000 CFU/mL; >5 wbc/hpf
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Urinalysis and gram stain are recommended
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Urine culture and sensitivity should be performed
routinely to facilitate cost-effective use of antibiotics
Non-pregnant patients with no signs and symptoms of
sepsis, adherent to treatment and likely to return for
follow-up may be treated as outpatients
ACUTE UNCOMPLICATED PYELONEPHRITIS
IN WOMEN
INDICATIONS for ADMISSION:
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inability to maintain oral hydration or take medications
concern about compliance
uncertainty about the diagnosis
severe illness with high fever, severe pain, marked
debility
signs of sepsis
ACUTE UNCOMPLICATED PYELONEPHRITIS
IN WOMEN
High resistance rates to TMPSMZ, thus it is no longer
recommended for empiric
treatment; can ONLY be used
when the organism is
susceptible to it on culture and
sensitivity test
Aminopenicillins (amoxicillin or
ampicillin) not recommended
DRUG
DOSAGE
DURATION
OFLOXACIN
400 mg BID
14 days
CIPROFLOXACIN
500 mg BID
7-10 days
LEVOFLOXACIN
250 mg OD
7-10 days
ASYMPTOMATIC BACTERIURIA IN ADULTS
 > 100,000 cfu/ml of one or more uropathogens in 2 consecutive
midstream urine specimen or in one catheterized urine specimen in the
absence of symptoms attributable to UTI
Screening:
• who will undergo genitourinary manipulation or instrumentation
• post-renal transplant patients up to the first six months
• DM patients with poor glycemic control
• ALL pregnant women
ASYMPTOMATIC BACTERIURIA IN ADULTS
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Any antibiotics for AUC can be used for treatment of ASB
in the above group of patients
7-14 day course is recommended, except for pregnant
women
Routine screening and treatment is not recommended for
healthy adults
URINE CULTURE is the recommended screening test, but
urine microscopy and stain may be used in the absence of
culture
UTI IN PREGNANCY
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> 100,000 cfu/ml of one or more uropathogens in
2 consecutive midstream urine specimen or in one
catheterized urine specimen in the absence of
symptoms attributable to UTI
Must be screened on their first prenatal visit between
9-17 wks AOG
URINE CULTURE of clean catch midstream urine is
the test of choice
UTI IN PREGNANCY
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Antibiotic treatment must be initiated upon diagnosis
Follow-up cultures one week after completing the
course of treatment
Treatment
- Nitrofurantoin (not for those near term)
- Co-amoxiclav and cephalexin
- Cotrimoxazole (not in the 1st and 3rd trimester)
- 7-day course is recommended
RECURRENT UTI
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Episodes of acute uncomplicated UTI documented
by urine culture occurring >2x/yr in a nonpregnant woman without known urinary tract
abnormality
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Treatment of individual episodes: 7-day treatment
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Prophylaxis (continuous and post-coital)
PROPHYLAXIS for Recurrent UTI
NORFLOXACIN
TMP-SMZ
CIPROFLOXACIN
OFLOXACIN
LOW DOSE DAILY
200 mg HS
40/200 mg HS
SINGLE DOSE
200 mg
40/200 mg
125 mg HS
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125 mg
100 mg
COMPLICATED UTI
CRITERIA
Presence of INDWELLING catheter or intermittent
catheterization
INCOMPLETE EMPTYING of the bladder with >100 ml
retained urine post-voiding
OBSTRUCTIVE UROPATHY due to bladder outlet
obstruction, calculus and other causes
Renal TRANSPLANT
Diabetes Mellitus
UTI in Males except in young males presenting exclusively
with lower UTI symptoms
COMPLICATED UTI
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significant bacteriuria is >100,000 cfu/ml
Urine sample for gram stain, culture and sensitivity
testing pretreatment is a MUST
Recommendation for mild to moderate illness:
oral fluoroquinolones for 7-14 days
A repeat urine culture after one to two weeks of
therapy
COMPLICATED UTI
ORAL REGIMEN
DOSAGE
DURATION
NORFLOXACIN
400 mg BID
14 days
OFLOXACIN
200 mg BID
14 days
CIPROFLOXACIN
250 mg BID
14 days
LEVOFLOXACIN
250 mg OD
10 - 14 days
UTI IN MALES
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Generally considered complicated
However, the 1st episode of symptomatic LUTS occurring
in young (15-40 years old) otherwise healthy sexually
active men with no clinical or historical evidence of
structural or functional urologic abnormality is
considered uncomplicated UTI
Significant pyuria is >5wbc/hpf in a clean catch
midstream urine specimen
TREATMENT: 7-day antibiotic regimen of TMP-SMZ or
Fluoroquinolones may be used
HYPERTENSION
JNC VII
NORMAL
<120
<80
PREHYPERTENSION
120-139
80-89
HPN STAGE 1
140-159
90-99
HPN STAGE 2
>160
>100
HYPERTENSION
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Diagnostic workup:
- FBS
- U/A
- serum Crea
- Serum K
- Lipid profile (HDL,LDL, Chole, Trigly)
- 12 L-ECG
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Treat to BP < 140/90 or < 130/80 mmHg in
patients with diabetes or chronic kidney
diseases
HYPERTENSION
HYPERTENSIVE URGENCY
- no end organ damage
- oral medications given initially
- lower BP within 2-3 days
HYPERTENSIVE EMERGENCY
-(+) changes in sensorium, papilledema, or CHF
- IV meds given STAT
- lower BP within 24 hours
HYPERTENSION
PO MEDICATIONS:
1. Calcibloc (Nifedipine)
• 5-10 mg SL or PO, Q30 mins
2. Captopril (Capoten)
• 25 mg SL or PO, Q30 mins
3. Clonidine ( Catapress)
• 75 mcg SL or PO, Q1
HYPERTENSION
HYPERTENSION
HYPERTENSION
BRONCHIAL ASTHMA
ASTHMA
GINA 2008
PULMONARY TUBERCULOSIS
ATS CLASSIFICATION
0 – No TB exposure
1 – TB exposure, No evidence of infection
2 – TB infection, No evidence of disease
3 – TB clinically active
4 - TB not clinically active
5 – TB suspect (diagnosis pending)
WHO CLASSIFICATION of PTB
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Pulmonary Tuberculosis (PTB)
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Smear positive
- if at least two sputum specimens are AFB (+).
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Smear negative
- if none of the specimens are AFB (+).
Extrapulmonary tuberculosis (EPTB)
CATEGORIES of PTB
NEW CASE:
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A patient who has never had treatment for TB or,
if with previous anti-TB medications, that was
taken for less than four weeks.
RELAPSE:
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A patient who has been declared cured of any
form of TB in the past by a physician after one
full course of anti-TB medications, and now has
become sputum smear (+)
CATEGORIES of PTB
RETURN AFTER DEFAULT (RAD)
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A patient who stops taking his medications for two
months or more and comes back to the clinic smear (+).
FAILURE
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A patient who, while on treatment, remained or became
smear (+) again at the fifth month of anti-TB treatment or
later; or a patient who was smear (-) at the start of
treatment and becomes smear (+) at the 2nd month.
CATEGORIES of PTB
TRANSFER-IN
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A patient whose management was started from
another area and now transferred to a new clinic
CHRONIC CASE
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A patient who became or remained smear (+) after
completing fully a supervised retreatment regimen
DIAGNOSIS of PTB
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In the Philippines, cough of two weeks or more should make
the physician and/or other healthcare workers suspect the
possibility of pulmonary tuberculosis. [Grade A
Recommendation]
Cough with or without the following: night sweats, weight loss,
anorexia, unexplained fever and chills, chest pain, fatigue and
body malaise, is suggestive of TB.
A patient exhibiting cough of two weeks or more with or without
accompanying symptoms will be referred to as a TB
Symptomatic
INITIAL WORK-UP
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The initial work-up of choice for a TB symptomatic is the
sputum microscopy. All patients who present with cough
of two weeks or more should preferably have three, but
at the least two sputum specimens sent for sputum
microscopy for Acid Fast Bacilli (AFB). [Grade A
Recommendation]
Sputum microscopy is still the most efficient way of
identifying cases of tuberculosis.
INITIAL WORK-UP
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Sputum smear for AFB is available, accessible,
affordable, with results rapidly available, correlates
well with infectiousness.
While there is new evidence that the third sputum
specimen usually contributes minimally to the
diagnosis of active tuberculosis, three sputum
specimens are still recommended until the same
findings are validated in the local setting. [Grade C
Recommendation]
SPUTUM MICROSCOPY
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Patients must be encouraged to bring up sputum and not
saliva.
Sputum collected first thing in the morning for three
consecutive days is recommended [Grade C
Recommendation].
SPUTUM MICROSCOPY
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Other modified schedules to allow collection in the
shortest number of days and clinic visits is likewise
acceptable [Grade C Recommendation]: Advise the
patients to collect three sputum specimens within two
days as follows:
First Specimen: Spot specimen collected at the time of first
consultation
 Second Specimen: Early morning specimen
 Third Specimen: Second spot specimen collected when patient
comes back the next day.
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PULMONARY TUBERCULOSIS
TREATMENT COMPLETED:
• treatment completed but does not meet criteria to be
classified as "cure" or "failure“
TREATMENT FAILURE:
• AFB Sputum Smear (+) after five months of treatment OR AFB
Sputum Smear (-) before treatment and becomes (+) during
treatment
TREATMENT
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The recommended treatment regimen for all adults newly
diagnosed with smear-positive tuberculosis and no history
of treatment is a short-course chemotherapy (SCC)
regimen, consisting of two months of isoniazid, rifampicin,
pyrazinamide and ethambutol (2HRZE) in the initial phase,
and 4 months of isoniazid and rifampicin (4HR) in the
continuation phase [Grade A].
The initial phase of treatment (2HRZE) should be given
daily, followed by daily or thrice-weekly administration of
isoniazid and rifampicin during the continuation phase.
WHO TREATMENT REGIMEN FOR TB PATIENTS
WHO
Category
TB Patients
Initial
Phase
Cont.
Phase
4HR
I
New Smear (+) PTB;
New smear (-) PTB w/ extensive parenchymal
involvement;
New cases of severe form of extrapulmonary TB
2 HRZE
II
Sputum smear(+);
Relapse;
Treatment failure;
Treatment after interruption
2HRZES 5HRE
and
1HRZE
III
New smear(-) PTB (other than Category I patients);
New less severe forms of extrapilmonary TB
2HRZE
4HR
TREATMENT
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The recommended dosages for daily and thrice-weekly
administration in mg/kg body weight are as follows:
Drugs
Isoniazid
Daily (range)
Thrice-weekly (range)
10
Rifampicin
10 (8-12)
10 (8-12)
Pyrazinamide
25 (20-30)
35 (30-40)
Ethambutol
15 (15-20)
30 (25-35)
Streptomycin
15 (12-18)
15 (12-18)
DIABETES MELLITUS
DIABETES MELLITUS
DIABETES MELLITUS
COMPONENTS OF COMPREHENSIVE
DIABETES MELLITUS EVALUATION
COMPONENTS OF COMPREHENSIVE DM EVALUATION
DIABETES MELLITUS
OBESE PATIENTS
BIGUANIDES
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Metformin 500mg OD, BID, TID
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Optimal dose 1,500mg/day
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Starting dose: 500mg BID after meals
DIABETES MELLITUS
B. ELDERLY (>60 YEARS)
SULFONYLUREAS
 Glibenclamide 1.25-20 mg OD or in divided doses
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starting dose: 5mg OD 30min before meals
Glipizide 2.5-30 mg OD or in divided doses
Gliclazide 80-240 mg OD or in divided doses
Glimepiride 1-4mg/day OD
DIABETES MELLITUS
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ACE INHIBITORS may be given which may slow down
the development of micro-albuminuria
• Fosinopril 10mg/tab OD
• Enalapril 10mg/tab OD
ASA 80mg/tab, OD may also be given.
THANK YOU!