Outpatient
Chronic stuff
#Hypertension
Chronic. Per 2022 Cochrane Review goal BP <160/100 (PMID 36398903). Well controlled with home regimen. No acute issues at this time.
-Continue home medication.
-First line therapy per ACC guidelines: ACE/ARB, thiazides, CCBs
-HCTZ equivalent to chlorthalidone for MACE and mortality
Ishani A, Cushman WC, Leatherman SM, Lew RA, Woods P, Glassman PA, Taylor AA, Hau C, Klint A, Huang GD, Brophy MT, Fiore LD, Ferguson RE; Diuretic Comparison Project Writing Group. Chlorthalidone vs. Hydrochlorothiazide for Hypertension-Cardiovascular Events. N Engl J Med. 2022 Dec 14. doi: 10.1056/NEJMoa2212270. Epub ahead of print. PMID: 36516076.
Saiz LC, Gorricho J, Garjón J, Celaya MC, Erviti J, Leache L. Blood pressure targets for the treatment of people with hypertension and cardiovascular disease. Cochrane Database Syst Rev. 2022 Nov 18;11(11):CD010315. doi: 10.1002/14651858.CD010315.pub5. PMID: 36398903; PMCID: PMC9673465.
#resistant HTN
Uncontrolled blood pressure despite 3 drugs (including a diuretic)
- add spironolactone
-plasma aldosterone:plasma renin activity >20; aldosterone level >15 suggests 1˚ hyperaldosteronism (not effected by ace/arb, but cannot order this test if already on spironolactone (false negative))
#Hyperlipidemia
Chronic. Currently on statin therapy for treatment. Patient tolerating medication well. No acute issues at this time.
-Continue home medication.
-ASCVD calculation:
-Recommend high/moderate intensity statin
-https://tools.acc.org/StatinIntolerance/#!/
#Coronary vascular disease
Encouraged Mediterranean Diet (CORDIOPREV, Lancet 2022)
#Chronic Insomnia
As defined by the AASM 2021 guideline, >3 nights per week for >3 months.
Current medical regimen (including OTCs):
Medical workup: no evidence of hyper/hypothyroidism, OSA, BPH, restless leg syndrome, medication side effect (including OTCs/herbals); concurrent anxiety/depression
Addressed possible underlying etiology, diuretic use, psychostimulant use, nighttime liquid intake, late-night meals, late-night exercise
Per AASM 2021 guideline, CBT-I first line therapy; sleep hygiene monotherapy is insufficient
Counseled against alcohol for self treatment of insomnia.
Counseled patient to reach out to Society of Behavioral Sleep Medicine CBT-I practioner list.
Counseled on short and long term risks of medication.
Underlying perception of sleep:
Barriers to CBT-I:
Motivation to enact lifestyle change:
CBT-I components:
Sleep restriction: start at 5-6 hours nightly with predetermined wakeup time, with goal of increasing sleep efficiency
Stimulus control: limit use of bed to sleep, and must leave bed if >15 minutes without achieving sleep
Cognitive therapy: addressed unrealistic expectations about sleep need, misattribution about cause, catastrophizing effects, and dysfunctional belief about how to improve sleep
Sleep hygiene: minimize caffeine consumption 8 hours prior to sleep, reduce electronic use, bedroom environment to be dark, quiet, and comfortable
Relaxation exercises: progressive muscle relaxation, autogenic training, imagery
Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN, Heald JL. Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2017 Feb 15;13(2):307-349. doi: 10.5664/jcsm.6470. PMID: 27998379; PMCID: PMC5263087.
Libman H, Zhou ES, Heckman E, Smetana GW. How Would You Manage This Patient With Chronic Insomnia? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med. 2022 Dec;175(12):1746-1753. doi: 10.7326/M22-2817. Epub 2022 Dec 13. PMID: 36508740.
Edinger JD, Arnedt JT, Bertisch SM, Carney CE, Harrington JJ, Lichstein KL, Sateia MJ, Troxel WM, Zhou ES, Kazmi U, Heald JL, Martin JL. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2021 Feb 1;17(2):255-262. doi: 10.5664/jcsm.8986. PMID: 33164742; PMCID: PMC7853203.
Social history:
Tobacco
Alcohol
Recreational drugs
Caffeine
Diet
-daily fruit
-daily vegetable
-caloric bevarages?
-recording calories?
-sweets?
-snacking?
-diet approach?
Exercise
-cardiovascular
-strength
Sleep
Who lives at home
Safe at home
Hobbies
Sexual history:
Number of sexual partners in last year:
Frequency:
Difficulty:
Last menstrual period:
Birth control:
Geriatric history:
What matters most to you?
What does a good day look like?
Toenail length (2mm per month)
Loss of executive function
Decreased flexibility/muscle strength
Caregiver burnout, social isolation
Poor vision
Timed get up and go (no hands, walk 10 feet, come back): >12 seconds increased risk of falls
Interventions to decrease fall risk are most effective when combined together and include physical and occupational therapy, home modifications (safe furniture, remove environmental hazards), use of appropriate assistive devices for ambulation and medication review
Cognitive:
Cognitive Screening Tests
The Mini-Cog is a quick screening test which assesses the ability to recall three words and draw a clock. If unable to complete successfully, need a more elaborate test
If cognitive tests show impairment, rule out reversible causes like hearing loss, medications, hypoglycemia, nutritional deficits, thyroid disorders, or electrolyte abnormalities
ADLs:
IADLs:
Who lives at home?
Advanced care planning?
Living will?
Falls in last 6 months?
DEXA?