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Practical Pearls for
Primary Care
Evaluation and Treatment
of Hypertension
A 58 yo man is diagnosed with
hypertension. His BP’s are 160/96, 160/100,
and 158/96 on 3 outside readings. He has
been on a low sodium diet and he is not obese.
PMH- hyperlipidemia, GERD and gout. What
would be the most appropriate treatment?
A) Low salt diet and exercise
B) Hydrochlorathiazide
C) Doxazosin
D) ACE inhibitor
When Thiazides Are Not A
Good Choice
History of Gout
 Creatinine > 1.6
 Lithium use
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Diuretic Choice
Strongly consider chlorthalidone
 Long acting, great data
 Major drawback has been hypokalemia
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Pearls in the Treatment of Hypertension
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Remember when not to use hydrochloathiazide:
renal insufficiency , gout
Chlorthalidone has longer half life, better efficacy
than HCTZ
Spironolactone avoids hypokalemia, avoid in
renal insufficiency, be careful if patient on an
ACEI or ARB. Remember gynecomastia
Losartan can lower uric acid
A 60 yo man presents for follow-up of
hypertension. He has been taking medication
(Lisinopril) for the past 3 months. His most recent
outside blood pressure readings are 156/94, 150/96,
158/92. PMH: Type 2 DM, GERD, depression. Meds:
Lisinopril 20mg qd, Rabeprazole 20mg qd, Sertraline
50 mg qd, Glyburide 10 mg qd.
What do you recommend?
A) No changes in therapy
B) Increase Lisinopril to 20 mg BID
C) Add Hydrochlorathiazide 12.5 mg qd
D) Add Amlodipine (Norvasc) 5mg qd
E) Add Clonidine .1mg BID
Combination Therapy
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Low doses of thiazide can be very effective in
combination with ACE inhibitors (12.5 mg of
thiazide)
Thiazide ACE combination can be further
enhanced by moderate dietary salt restriction
ACE/Amlodipine combination may have CV
benefi slightly better than ACE/diuretic in high
risk diabetic paients
A 58 yo woman is seen for treatment of hypertension. She
has not ever had good control of her hypertension since
treatment was started 2 years ago. She has been taking her
medications faithfully. Meds: Felodipine (Plendil), Atenolol ,
Clonidine, and Losartan (Cozaar). On exam her BP is 200/106
P-55.Labs- BUN 30, Cr 2.0, Na 137, K 4.0. ECG- LVH
What would you recommend?
A) Increase felodipine from 10mg a day to 10mg BID
B) Increase losartan from 50mg BID to 100mg BID
C) Add hydrochlorathiazide 12.5 mg qd
D) Add hydrochlorathiazide 25 mg qd
E) Add furosemide 40 mg BID
Refractory Hypertension
Occurs in 5% of hypertensive patients
 Always carefully evaluate for medication
adherence.
 Worse with increasing obesity
 Think of secondary causes
 Sleep apnea
 Ingestion of substances that interfere with
treatment (especially NSAIDS)
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Treatment of Refractory
Hypertension
Most have too much volume.
Furosemide extremely useful, especially
if renal insufficiency present
 Strongly consider using spironolactone
 Simplify regimens if possible to improve
adherence
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AHA Recommendations For
Treatment of Hypertension
Indication
BP goal
Initial therapy
Low risk
<140/90 ACE/CCB/Thi
High risk
<130/80 ACE/CCB/Thi
With CAD <130/80 BB and ACE
CHF
< 120/80 BB/ACE/Aldo
Diuretics
B Blocker
No
No
Yes
Yes
How Can You Tell What
Kind Of Headache It Is?
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A 29 yo woman is evaluated for headaches.
She reports having headaches about twice a
month. She feels pain behind her right eye
and frequently pain on her forehead. Her
headaches often get better with 550 mg of
Naprosyn. She has never had visual problems
or nausea with her headaches. The
headaches are worse with exercise. About
once a month the headache is bad enough to
force her to leave work early.
What is the Most Likely Type of
Headache?
A)Migraine
B)Cluster
C)Muscle tension
D)Nitrate headache
Clinical Features of Tension Type
Headache
Mild Headache
 Often described as tightness, vice like
 Neck to forehead can be involved
 Often helped by NSAIDS
 Worse during times of stress
 Not disabling
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Clinical Features of Migraine
Headaches
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Family history common
Pulsating quality
Worse with activity
Mild to Severe in intensity
Can be disabling
History of motion sickness common
Nausea, photophobia, phonophobia may
occur
Diagnosing Migraine
POUNDing Pneumonic
 Pulsating
 Duration 4-72 hOurs
 Unilateral
 Nausea
 Disabling
If 4 criteria met LR is 24 for migraine
If 3 met LR 3.5
If 2 or fewer LR.41
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JAMA 2006: 296: 1274-1283
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A)
B)
C)
D)
A 29 yo woman presents for evaluation. She reports
that she has frequent headaches over the past 12
months that include pressure pain on her forehead,
under her eyes and over her cheeks. She usually
has nasal congestion as well. She has not had any
fevers or purulent nasal discharge. What is the
most likely problem?
Cluster headaches
Migraine headaches
Sinus headaches
Tension headaches
“Sinus” Headaches Are Usually
Migraine Headaches
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2991 patients screened who reported at least 6
headaches during the previous 6 months self
diagnosed or physician diagnosed as sinus
headaches
88% of these patients met IHS criteria for migraine
HA (80%) or migrainous criteria (8%).Most common
sx patients reported were sinus pressure (84%), sinus
pain (82%) and nasal congestion (63%)
Arch Intern Med 2004;164 (16): 1769-1772
Sinus, Allergy and Migraine
Study
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100 patients recruited who believed they had sinus
headaches. All received a detail history and PE and
given headache diagnosis based on HIS criteria
Final diagnosis were as follows: Migraine with or
without aura 52%, probable migraine 23%, chronic
migraine with medication overuse HA 11%,
nonclassifiable HA 9%. 76% of migraine patients
reported pain in the distribution of the 2nd division of
the trigeminal nerve and 62% experienced bilateral
forehead and maxillary pain with their HA’s.
Headache 2007;47:213-224
Treatment of Sinus Headache as
Migraine: The Diagnostic Utility of
Triptans
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To determine the response rate to triptans in
alleviating “sinus headache” in patients with
endoscopy and CT negative sinus exams
Prospective study of patients with physician or patient
self diagnosed sinus headaches with negative
workup all treated with triptans
54 patients enrolled, 38 completed follow up. 31
patients (82%) had significant reduction in headache
pain with triptan use, 35 (92%) had a response to
migraine directed therapy.
Laryngoscope 2008;Dec; 2235-2239.
Tip Offs That a Headache is Not
of Sinus Orgin
Absence of fever
 Absence of purulent drainage
 Chronicity
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Frequency of Headache Types
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Tension Type – Most common
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Migraine - Common
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Cluster - Rare
Treatment Pearls for Migraine
Role of Metoclopramide
Good efficacy when combined with
NSAID. Equivalent to sumatriptan oral if
patient has nausea.
 My boost effect of oral triptan or other
oral migraine treatments
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Metoclopramide vs Hydromorphone
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Retrospective cohort study to evaluate metoclopramide vs
hydromorphone for initial ED treatment of migraine
200 patients, 51 received IV or IM hydromorphone, 95
received IV metoclopramide and 54 received a different
medication.
Using a 1-10 pain scale, mean pain scale reductions were
2.3 for hydromorphone, 3.7 for metoclopramide and 2,8 for all
other meds (p<.001).
Less rescue meds and faster ED discharge with
metoclopramide
J Pain 2008;9 (1): 88-94.
Sumatriptan + Naproxen
Sustained pain free response 2-24 hours, the
combination is superior to either drug by itself
(p<.01) . Dose used 85 mg
sumatriptan/500mg naproxen (1)
 In patients with poor prior response to triptans,
the combination was significantly more
effective than placebo (p<.001) (2)
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1)JAMA 2007;297:1443-1454.
2) Headache 2009;49:971-982.
Oral treatment protocol for
moderate to severe HA
NSAID + motility drug (Metoclopramide)
no relief
Oral triptan
no relief
Oral narcotic
no relief
ER/office visit for IV therapy
Infectious Disease Pearls
A 55 yo man presents with discomfort in his
leg and swelling. He has no chronic medical
problems. He has had problems with athlete’s
foot. Labs: WBC 12,000
VS : T- 37.5 BP 130/70 P 88
What do you recommend?
A.
B.
C.
D.
E.
Metronidazole
Ciprofloxacin
TMP/Sulfa
Vancomycin
Cefazolin
The Role of A-Hemolytic Streptococci in Causing
Diffuse, Nonculturable Cellulitis
- All patients admitted to one hospital with diffuse
cellulitis over a 3 year period were enrolled. 179
were studied
- All patients had serologic studies for exposure to
streptococci, response to antibiotics were recorded
- 131 positive for strep, 48 negative
- 71/73 (97%) evaluable patients with positive strep
studies responded to B lactams, 21/23 (91%)with
negative studies responded to B lactams (overall
respones rate 95%)
Medicine 2010;89: 217-226
Clinical Practice Guidelines for Treating MRSA
- For outpatients with nonpurulent cellulitis
(no purulent drainage or exudate, no abscess)
empirical therapy for infection due to B
hemolytic streptococci is recommended.
- Coverage for CA-MRSA is recommended in
patients who do not respond to B lactam
therapy.
Clin Inf Dis 2011; 52(3):e18-e55
A 22 yo woman presents with dysuria, frequency
and hematuria. No fever, chills or flank pain.
Allergies:sulfa. Ua- 20-30 WBC’s/HPF
What do you recommend?
A.
B.
C.
D.
E.
Urine culture
TMP/Sulfa
Ciprofloxacin
Nitrofurantoin
Cephalexin
International Practice Guidelines for
Uncomplicated Cystitis/Pyelonephritis in Women
Cystitis recommended antibiotics
- Nitrofurantoin 100mg BID X 5 days
- TMP/Sulfa DS BID X 3 days (if resistance in
the community <20% and not used in the
past 3 months)
- Fosfomycin 3 gram single dose
Clin Inf Dis 2011; 52(5): e 103-120
International Practice Guidelines for
Uncomplicated Cystitis/Pyelonephritis in Women
Pyelonephritis
- Always get a urine culture/sensitivities
- Ciprofloxacin 500 mg BID (with IV initial dose if
appropriate) if community resistance to FQ <10%
- If >10% FQ resistance, start with 1 gm ceftriaxone
dose or 24h dose of aminoglycoside
- Further treatment based on urine sensitivities
Clin Inf Dis 2011; 52(5): e 103-120
A 66 yo woman is seen for fevers and diarrhea. Had
dental surgery 6 months ago and was given a 7 day
course of amox/clav. Afterwards she developed fever and
diarrhea and was dx with C diff. She has had 2 more
recurrences since treated with vancomycin each time.
Meds : Citalopram,omeprazole, zolpidem.
Her stool returns positive for C diff . What do you
recommend?
A.
B.
C.
D.
Metronidazole X 2 weeks
Vancomycin X 1 month (with taper)
Cholestyramine
Fecal transplant
Fecal Transplant for Recurrent
C Difficile Infection
- 19 patients with recurrent CDI treated with fecal
transplant delivered through colonoscope
- 18 patients had immediate response with resolution.
One patient recovered after a 2nd transplant. Three
had recurrences after receiving antibiotics.
J Clin Gastroenterology 2010;44: 567-570.
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A)
B)
C)
D)
E)
A 36 yo woman presents with facial pain,
congestion and low grade fevers for the past
7 days. On exam, T 37.9, P 80. Tenderness
over left maxillary sinus.
What do you recommend?
No antibiotic treatment
Amoxicillin
Amoxicillin/Clavulanate
Azithromycin
Levofloxacin
IDSA Guidelines for Treatment of
Rhinosinusitis
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Treat with antibiotics at 10 days of symptoms, treat
earlier if A)T >39 AND purulent nasal discharge or
severe facial pain B) “Double sickening”
Amoxicillin/Clavulanate the preferred antibiotic
Do not use Azithromycin or TMP/Sulfa
Quinolones or Doxycycline alternate choices for PCN
allergic patients
Clinical Infectious Diseases 2012;54(8):1041–5
Using Common Drugs
A 60 yo man returns for annual follow up. He
has a history of hyperlipidemia and is being
treated with atorvastatin 40 mg daily. His other
medications include sertraline, omeprazole and
vitamin D. What would you recommend?
A) Check fasting lipids
B) Check fasting lipids , CPK
C) Check fasting lipids, CPK, ALT,AST
D) Check fasting lipids, AST,ALT
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Is There Any Benefit to Checking Liver Enzymes
in Statin Treated Patients?
408 patients undergoing statin treatment with
at least one lab test (AST/ALT or CK) >10%
above normal
 36 (8.8%) were symptomatic when tests were
drawn. Of 40 patients who had additional
evaluation, only 2 had treatment changes (both
symptomatic)
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Expert Opinion Drug Saf 2011 (Nov 1)
What is the Yield of Testing
Transaminases?
Retrospective review of a primary care practice
 1014 of 1194 patients on a statin had a
monitoring test done in a 1 year period
 10 of 1014 patients (1%) had a significant
transaminase elevation, and 5 (0.5%) had a
moderate transaminase elevation, but none
were due to the statin
 Arch Intern Med 2003;163():688-92
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A 60 yo man with Type 2 DM presents for evaluation.
He has a strong family history of colon cancer . His
other problems include CRI and hypertension. Most
recent HBA1C was 7.4, He has been managing his
diabetes with diet. Most recent Cr 1.8 (CrCl 49). What
do you recommend for this patient?
A) Metformin
B) Glypizide
C) Glyburide
D) Glargine
Reduced Risk of Colorectal Cancer With
Metformin in Patients With Type 2 DM
Meta-analysis of 4 studies, with 107,961
diabetic patients
 Metformin treatment was associated
with a significantly lower risk of
colorectal cancer (RR .63, CI .47-.84,
p=.002)
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Diabetes Care 2011; 34: 2323-2328
Metformin Package Insert
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Lactic acidosis risk of 0.03 cases/ 1000, with
a fatality rate of 0.015/1000
Discontinuation if Cr >1.5 in men and >1.4 in
women, and advises against initiation in
people > 80 years of age unless they have a
normal creatinine clearance
Other contraindications include congestive
heart failure requiring medical management,
acute or chronic metabolic acidosis, and
acute presentations of dehydration,
hypotension, and sepsis
Cochrane Review
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206 studies
47,800 person-year of exposure to metformin,
and 38,200 patient-years in the nonmetformin comparison group
no cases of fatal or non-fatal lactic acidosis in
either group
96% of studies allowed for at least one high
risk group to be included
Cochrane Database Syst. Rev.; 2005 Jul 20;(3)
Incidence of Lactic Acidosis in
Metformin Users (1)
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Patients with a metformin prescription from 1980-1995
in Saskatchewan Health administrative database.
11,797 patients with 22,296 person years of exposure.
Two patients had a hospital diagnosis for lactic
acidosis (rate 9 /100,000)
Rate of lactic acidosis in diabetic patients not on
metformin 9.7/100,000 (2).
1. Diabetes Care 1999 Jun: 22(6) 925-7
2. Diabetes Care 1998; 21:1659-1663
Rational Recommendations for
Metformin Use
eGFR
>60
<60 and > 45
<45 and >30
<30
Action
No contraindications
Continue use, check Cr
every 3-6 months
Use lower dose (1/2 dose)
Check Cr every 3 months
Do not start new patients
Stop Metformin
Diabetes Care 2011;34: 1431-1437
Does Metformin Improve Outcomes in
Patients With Type 2 DM and CHF ?
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12,272 new users or oral diabetes agens between 1991-1996
reviewed. 1,833 had CHF
Of these patients treated for DM with CHF, 208 received
metformin monotherapy, 773 were given sulfonylurea
monotherapy and 852 received combination therapy.
Fewer deaths occurred in patients receiving metformin
monotherapy (52% receiving sulfonylurea’s died, 33% receiving
metformin monotherapy died, 31% receiving combination
therapy died)
Diabetes Care 2005; 28: 2345-2351.
Primary Care Urology
A 84 yo man presents with hematuria. He had an episode last
week, but has had hematuria for the past 4 days. He has had
some hesitancy , frequency and nocturia for several years.
Meds: ASA, MVI, omeprazole. A urinalysis is done which just
shows RBC’s, no WBC’s. Cystoscopy shows no bladder
malignancy. CT scan of the abdomen shows no renal lesions.
What do you recommend to help stop future hematuria?
A) Tamsulosin
B) Weekly dose of norfloxacin
C) Finasteride
D) Pyridium
E) Stop his aspirin
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Finasteride Treatment of Hematuria in Patients
with BPH
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Meta-analysis of multiple small studies for
using finasteride for treatment of BPH
associated hematuria
Use of finasteride resulted in decreased
hematuria (OR .11, 95% CI: .06-.21, p<.05)
over 12 months
Zhonghua Nan Ke Xua. 2006; 16 (8):726-729.
How Finasteride Works to Decrease
Hematuria
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Randomized 30 patients to receive finasteride 5 mg vs placebo
for 4 weeks prior to planned prostetectomy.
The suburethral and hyperplastic prostate specimens were
examined for microvessel density (MVD).
MVD was the same in the hyperplastic areas for both, but was
statistically lower in the suburethral area in patients taking
finasteride ( 9.08 vs 13.94, p<.05)
Urol Int 2008; 80 (2): 177-80.
What is Finasteride Good for?
Symptoms of BPH- marginal
 Decreasing risk of acute urinary
obstruction
 BPH related hematuria
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