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Primary Care Check List for Chronic Disease Follow Up

Hypertension
Baseline: lytes, BUN/Cr/GFR, glc, HCT, lipids, TSH, UA, ECG, CXR
Goal: <140/90; <130/80 if DM, CKD, CVD, >10% Framingham CV risk, <120/80 if HF, <125/75 if >1g proteinuria
Lifestyle: Low Na <2.6g/day, fruits & vegetables, low sat fat & total fat (DASH), exercise 30min 3-4d/week, smoking, alcohol intake
Treatment: Per JNC 7. If Stage II will need 2 meds.
Follow up: Stage I 2 months, Stage II 1 month, med change 1 month, stable 6-12 months

Dyslipidemia
Screen: Age 35M, 45W, >20 if risk factors
1.) ? CHD: CHD, Sx carotid artery disease, PAD, AAA
2.) Risk Factors: []Age>45M, >55W; []HTN>140/90 or on Tx; []HDL<40; []Fam Hx CHD <55M, <65W; []Smoking; [] - 1 for HDL>60
3.) 2+ Risk Factors w/o CHD equivalent -> Assess 10 yr risk: >20, 10-20, <10

 

Goal LDL / Non-HDL

Initiate TLC

Initiate Drugs

AMI

<70

 

 

>20% or CHD

<100  - 130

>100

>130

2+ RF 10-20%

<130  - 160

>130

>160

2+ RF <10%

<130  - 160

>130

>160

0-1 RF

<160  - 190

>160

>190

TLC: exercise 30min 3-4d/week, diet <7% Sat. Fat, <200mg chol./day, soluble fiber 10-25g/day, plant stanols/sterols 2g/day
Drug: begin statin 3mo after TLC
4.) Metabolic Syndrome: 3 of the following: Abdominal Obesity >40in M, >35in W; TG>150; HDL<40M, <50W; BP >130/85, FG>110
5.) Hypertriglyceridemia: >200 then treat Non-HDL with nicotinic acid or fibrate, if >500 tx TG's first with <15% calories from fat diet
6.) Low HDL: if TG 200-499 treat Non-HDL, if TG<200 (isolated low HDL) treat with nicotinic acid or fibrate in CHD or CHD equivalent

CAD
Dx: Hx of MI? Stress test? EF per echo? Cath?
Drugs: []ASA []clopidogrel []beta-blocker []acei if CHF, decr. EF, HTN, DM if not, at least 4-6 weeks post ACS.[]statin to <70 (?atorvastatin 80) []aldosterone antagonist if EF<40 & sings of HF []nitro standing if symptomatic []nitro PRN for all

HF
Dx: Systolic or Diastolic? Left or Right? Cor Pulmonale? EF per echo? CM? Dilation, hypertrophy, restriction?
Class: I sx w/ > than ordinary activity, II sx w/ ordinary activity, III sx w/ minimal activity, IV sx @ rest.
TLC: Na <2g/day, fluid restrict, exercise training, stop smoking, stop EOTH
Drugs: []AEI/ARB []hydralzine&nitrates (intolerable to ACEI/ARB or blacks Class III/IV) []beta-blocker []aldosterone antagonist (Class III/IV EF<35, post MI EF<40)

Diabetes Mellitus/Insulin Resistance
Screen: FBG 100-126 conisder 75g OGTT, FBG>126=DM2, Non FBG>200=DM2, 75g OGTT BG>200
Goal: A1c <7%
Follow up: A1c  q3-6 mo, lipid check q6-12 mo, microalbuminura yearly, retinal exam yearly, foot exam yearly

Osteoporosis
Screen: all women >65, consider men with low trauma fracture, chronic glucocorticoid use, hypoandrogenism, and IBD.
Formal Risk Factor Assessment: http://www.shef.ac.uk/FRAX/
Dx: DEXA scan if positive check CBC, TSH, Ca, Ph, ESR, 24 hour urine Ca, vitamin D. Optional: T in men, FSH/estradiol in premenopausal women, iPTH, SPEP/UPEP, celiac panel, w/u hypercortisolism.
Drugs: Calcium 1500mg/day (men>65 or menopause), Vitamin D 800mg, Bisphosphonate, raloxifene for post-menopausal

ASA
Men>45-79
Women>55-79

AAA
Screen: Men>65-79 who have smoked -> US
Follow up: If <4.0cm repeat q2-3years, if>4.0cm q6mo, >5.5cm refer to vascular surgeon

Prostate CA
DRE + PSA >50-75
AA and Family Hx >45

Breast CA
CBE 20-39 q3 years
Mammography q1-2 years +/- CBE >40

Cervical CA
Annual, >30 with 2-3 nl: q2-3 yr, stop >65 with 3 negative paps

Colon CA
Age >50, if Fam Hx >40
FOBT yearly and/or flex-sig q5 yr
Colonoscopy q10 yr

Smoking Cessation
? Packs per day, willingness to quit, bupropion, nicotine replacement, varenicline, behavioral counseling
1-866-NY-QUITS

STD's
All women <25 screen chlamydia/gonorrhea
Screen adolescents & adults at risk for HIV

Influenza
Age>50; possible pregnancy during season; COPD; asthma; CVD except HTN; renal, hepatic, hemtaological, metabolic disorders; DM; cognitive dysfunction, SCI, SZ d/o; nursing home residents, chronic care faciliies; HCW, caregivers & contacts to adults>50, caregivers and contacts of high risk groups. Contraindicated: egg allergy, allergy to vaccine, acute febrile illness if mod or severe, hx of GBS

Pneumococcal
Age>65, <65 if LTC, SNF, CHF, COPD, DM, ETOHism, cirrhosis, csf leak, asplenic, alaskan & american indian, maligancy, HIV, nephrotic syndrome, corticosteroids. 5 years after vaccination if 1st less than age 65.

Tetanus
Booster q10 yr

 

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