Professional Documents
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Dyslipidemia
* General Characteristics : - Secondary
a- Definition : A condition characterized by
elevated serum levels of total cholesterol( TC), low-
------------------------------------------------
density lipoprotein cholesterol (LDL-C)or non-high-
density lipoprotein cholesterol (none HDL-C).
This is associated with elevated risk for
cardiovascular disease. also lower levels of HDL-C
and, to a lesser extent, elevated triglyceride levels.
b- Lipid Parameter Function:
1.VLDL
- Carries triglycerides to peripheral
cells
- High levels may be associated with
increased CHD risk
2. LDL
- Carries cholesterol to cells ------------------------------------------------------
- High levels linked to increased
*Clinical Entities :
CHD risk
* Symptoms & Signs :
- Primary target of cholesterol-
reducing therapy
3.HDL
- Removes cholesterol from cells
- High HDL considered protective against CHD
- HDL >60 mg/dL decreases CHD risk
4.Lipoprotein(a)
- A complex of LDL and
apolipoprotein(a)
- Prevents LDL from being taken up
* Checking lipids:
by the Liver
1. Non fasting lipid panel measures HDL and
- Elevated Lp(a) is an independent
total cholesterol
risk factor for premature CHD
2. Fasting lipid panel Measures HDL, total
5.Triglycerides
cholesterol and triglycerides
- A neutral fat stored in adipose cells
LDL cholesterol is calculated:
- Positively correlated with risk for
LDL cholesterol = total cholesterol – (HDL +
CHD
triglycerides/5)
c. Causes of Hyperlipidemia *Values of Lipids:
- Primary * Total Cholesterol
1. Familial Hypercholestrolemia Abnormally of - < 200 → Desirable
the LDL receptor - 200-239 → Borderline
2. Familial hypertriglyceridemia High VLDL - ≥240 → High
production, decreased lipoprotein lipase activity * LDL
3. Familial Combined Hyperlipidemia LDL and - < 100 →Optimal
VLDL, increased secretions of VLDLs
- 100-129 → Near optimal 9- Chronic renal disease
- 130-159 → Borderline 10- Metabolic syndrome
- 160-189→ High *Management and Prevention:
- ≥ 190 → Very High
*HDL
- Low if <40 mg/dL in males and
< 50 mg/dl in females).
>60 high
* Serum Triglycerides
- < 150 → normal
- 150-199 → Borderline
- 200-499 → High
- ≥ 500 → Very High
* Screening :
1- Men over 35 and woman 0ver 45.
2- Anyone with atherosclerotic symptoms regardless
of age
3- Anyone with diabetes regardless of age
4- Family history of premature CVD
5- Inflammatory diseases (lupus, rheumatoid arthritis,
psoroasis)
6- Children of patients with severe dyslipidemia
7- Clinical signs of hyperlipidemia
8- Erectile dysfunction
Treatment of the metabolic syndrome
Treat underlying causes (overweight/obesity
and physical inactivity):
Intensify weight management
Increase physical activity
Treat lipid and non-lipid risk factors if they
persist despite these lifestyle therapies:
Treat hypertension
Use aspirin for CHD patients to reduce
prothrombotic state
Treat elevated triglycerides and/or low HDL
(as shown in Step 9 below)
Diabetes
Mellitus
* General Characteristics : D. Metabolic Syndrome (MS)
A. Definition : Any Three of the following. (AHA)
* an Endocrine disorder characterized by 1. Central obesity
hyperglycemia resulting from variable degrees of - waist circumference ≥ 102 cm for men and ≥ 88 cm
insulin resistance and deficiency. for women ( USA and Europe).
* DM is a leading cause of morbidity and mortality, > 94 and 80 cm in middle east countries)
costly yet controllable with a prevalence of 17.1% in 2. Triglycerides≥ 150 mg/dl (1.7 mmol/L)
Jordan. 3. HDL-cholesterol:
* Blood sugar management is only part of story. It is men < 40mg/dl (1.03 mmol/L),
important to ensure that Blood pressure and women < 50mg/dl (1.29 mmol/L)
cholesterol level are tightly controlled in order to 4. BP ≥ 130/85mmHg
reduce complications. 5. Fasting glucose≥ 100mg/dl (5.6 mmol/L)
B. Epidemiology
- worldwide prevalence is 9% in men and 7.9% in Pts should undergo a full cardiovascular risk
women in 2014. assessment and management should be aggressive to
( more than 85% of whom have type 2 variety). reduce the risk of CVD and type 2 D.M
- Type 2 DM is much more strongly inherited than
type 1 DM --------------------------------------------------
- The incidence of T2DM varies significantly among * Clinical Entities
and within different ethnic groups according to their A. Who should be screened for D.M
culture and lifestyles. a) T1DM: no indications for screening
b) T2DM: Testing should be considered in all adults
C. Classification of different types of Diabetes: who are overweight (BMI) ≥ 25 kg/m2) and have
1-T1DM:(beta-cell destruction, usually leading to additional risk factors:
absolute insulin deficiency) 1)Sedentary lifestyle
immune-mediated 2)Family history of DM.
idiopathic 3)Prior history of Pre-diabetes (annual screening)
2-T2DM:(constitutes 85% of all diabetics) is 4)Hypertension, Hyperlipidemia, Coronary artery
characterised by insulin resistance and variable disease.
insulin secretory defects
5)History of gestational DM or delivery of infant
3) Gestational diabetes. weighing over 4.5 kg
4) Other types:
a) Genetic defects in insulin production or action 6)Pregnant ladies
b) Exocrine pancreatic disease 7)History of PCOS
c) Associated with endocrinopathies * Community screening outside a health care setting
d) Drug induced is not recommended
e) Infection * In the absence of the above criteria testing should
* 50% of T2DM are not diagnosed begin at age 45 years
* If results are normal testing should be repeated at
IDDM NIDDM least 3 years intervals
Age <30 >30
Rate of onset Rapid Slow B. Diagnosis of Pre-diabetes
Body WT Thin obese 1.Impaired Fasting Glucose (IFG)
Ketosis Common rare FPG 100- 125 mg/dl (5.6-6.9 mmol/L)
HLA association Present absent 2.Impaired Glucose Tolerance (IGT)
Identical twins <50% >50% 2 hr plasma glucose 140- 199 mg/dl
(7.8- 11.0 mmol/L)
Islet cell mass Greatly reduced Slightly
- Both IFG and IGT are risk factors for future
reduced
diabetes and for
Endocrinopathies occasional rare - cardiovascular disease and associated with insulin
resistance and metabolic syndrome.
- Unless lifestyle modifications are made most people IGT 140-199
with pre-diabetes develop type 2 diabetes within 10 mmol/dl
(7.8-11
years. mmol/L)
DM ≥ 126 mg/dl ≥ 200mg/dl ≥ 200mg/dl
(7 mmol/L) (11.1 (11.1
mmol/L) mmol/L)
(with
symptoms)
*Clinical Presentation :
- Generally associated with hoarseness or loss of
voice.
- Symptoms: hoarseness of the voice,Fever
Swollen lymph nodes, dysphagia, odynophagia,
dyspnea, rhinorrhea, postnasal discharge, sore
throat, congestion, fatigue, and malaise.
* Treatment:
a. voice rest, analgesia,cool mist,hydration.
b. Nebulized epinephrine or oral steroid for
sever cases.
Minor Injuries inPrimary Care
A. Skin Injuries :
---------------------------
B. Muscle and tendons Injuries
- Strains : are caused by overstretching or tearing the
tendons or muscles that help support and move a
joint. Many strains are minor -just small tears in the
tissue -but some can be severe. * Shaken Baby Syndrome-a form of child abuse (it
- Sprains : are likewise caused by overstretching or can cause brain injury , retinal hemorrhage ,
tearing, but they occur in ligaments. developmental and behavioral defects ).
- Bruises: happen when a muscle, ligament, or ** Red Flags of Head Trauma
tendon sustains a blow forceful enough to injure 1.Becomes very drowsy
capillaries, so they break open and cause blood to 2. Behaves abnormally
collect under the skin and in the injured tissue. Most 3. Develops a severe headache or stiff neck
bruises are minor and heal with treatment at home. 4. Loses consciousness, even briefly
But some can be severe and take weeks or months to 5. Vomits more than once
heal. Bruising can even occur in vital organs, if the 6. There is severe head or face bleeding
injured tissue is a vital organ. 7. The person stops breathing
8. changes in vision, taste or smell
* Evaluation & Management of Muscle and 9. muscle weakness
tendons Injuries 10. inability to concentrate
1. Skip the heroics. 11. decreased reading comprehension
2. Don't wait. 12. diminished auditory comprehension
3. Begin RICE immediately. 13. irrational fears
Rest:Cut back on normal daily activities and avoid 14. problems with judgment
putting weight on the injured body part. ----------------------------------------------
Ice:Use an ice pack on the injured area for 10 to Needle stick injury-Post exposure prophylaxis
20 minutes at a time, anywhere from four to eight (PEP):
times per day. Don't use the ice pack for longer than 1) HIV
20 minutes, and wrap it in a T-shirt or thin towel so * Post exposure prophylaxis is Indicated if:
you don't burn your skin. - Source patient is individual with known HIV
Compression:To reduce pain and swelling, wrap infection or
the injured area with an elastic bandage not too - unknown HIV status who is epidemiologically at
tightly, though. higher risk of having HIV.
Elevation:Use pillows or blankets to raise the * HIV testing should be performed in all patients
injured limb above the level of the heart to minimize before starting antiretroviral PEP.
swelling. -Antiretroviral PEP should beinitiatedas soon as
** Delaying RICE treatment could mean more pain possible afterexposure:
and swelling and a longer recovery period. -Within 72 hours
------------------ -given for 28-day.
C. Head Trauma * Drugs:
- Head injuries include both injuries to the brain and -Tenofovir 300 mg plus emtricitabine 200 mg orally
those to other parts of the head, such as the scalp and once daily.
skull Plus:
- Head injuries are generally classified as closed or -raltegravir 400 mg orally twice daily for 4 weeks.
open (penetrating). * Follow-up with HIVantigen/antibody testing at 3
- Brain injuries may be diffuse, occurring over a wide and 6 months.
area, or focal, located in a small, specific area.
- Brain injury can be at the site of impact, but can 2)Hepatitis B post exposure prophylaxis
also be at the opposite side of the skull due to a go back to slide #32 there is a table
counter-coup effect 3) Hepaitis C Post Exposure prophylaxis
Traumatic subdural hematoma, a bleeding For HCV PEP , the HCV status of the source and the
below the dura mater which may develop slowly exposed person should be determined.
Traumatic extradural, or epidural hematoma, if HCV positive source, or source unknown but high
bleeding between the dura mater and the skull risk, follow-up HCV testing should be performed to
Traumatic subarachnoid hemorrhage determine if infection develops by testing HCV Ab at
Cerebral contusion, a bruise of the brain baseline and then at 3 and 6 months.
Concussion, a loss of function due to trauma -------------------------------------------------
A severe injury may lead to a coma or death