IM Group Case Report 2020

Intern’s
Case Report
OUR TEAM
CONTENTS
Objectives
Case Report
Salient Features
Differential Diagnosis
Initial impression
Case Discussion
Plans
Final Diagnosis
I. Objectives
OBJECTIVES
GENERAL: To present a case of Diabetes
Mellitus II and Hypertension
SPECIFIC:
To be able to recognize a case of Diabetes
Mellitus and Hypertension
To be able to enumerate differential diagnoses

of Diabetes Mellitus and Hypertension
To discuss the appropriate management of

each diseases
To discuss possible complications of each disease
II. Case
Presentation
•J.R.P.
• 52 y/o Female
GENERAL • Married
• Filipino
DATA • Roman Catholic
• Cook
• May 11, 1968
• Batangas City
• BATMC OPD: May 3, 2020
Chief Complaint:
HISTORY OF PRESENT ILLNESS
• intermittent episodes of constricting

nape pain graded 3-4/10,
• usually during lunch time
• spontaneously relieved by rest and
sometimes by taking a nap.
• BP ranged from 140-160/90-100
• intermittent episodes of nape

pain
• difficulty in falling asleep.
• 3-4 interrupted hours at night
• multiple trips to the bathroom
• straw colored and bubbly urine
• often thirsty
• frequent voiding
• persistent symptoms
• tingling sensation on
fingertips
• prescribed with:
• Metoprolol 50mg/tab OD
• Mefenamic Acid 200mg/tab
• Sleepasil tablet
• CBG high
• advised by her co-worker to take
Metformin 500mg/tab BID.
• still had difficulty in

sleeping and intermittent
nape pains
• Lost weight: 80kg to 75kg
• Denies chest pain or
palpitation.
PAST MEDICAL HISTORY
• No history of PTB treatment

• No history of Diabetes Mellitus,
Hypertension, Cardiovascular
Diseases, Thyroid Disorders,
Bronchial Asthma
• No history of previous blood
transfusions
• No known allergies to food and
medications
OBSTETRIC HISTORY
G5P5 (5005)
G1 – 1988 , girl, normal spontaneous
delivery at BatMC, no complications
G2 – 1990, girl, normal spontaneous
G3 – 1992, boy, normal spontaneous
G4 – 1995, girl, delivered via Cesarean
section at BatMC due to
Pre-eclampsia
G5 – 1998, girl, delivered via repeat CS
at BatMC, no complications
MENSTRUAL HISTORY
Last Menstrual Period: September
2019
Menarche: 13 years old
Interval: Regular
Duration: 5-7 days
Amount: 3-4 fully soaked pads/day
Symptoms: with dysmenorrhea
until the 2nd day of menstruation
SEXUAL HISTORY
Coitarche: 18 years old
Number of Sexual partners: 1 (husband)
No history of contraceptive use
GYNECOLOGIC HISTORY
No history of sexually transmitted
infections, dyspareunia, and
post- coital bleeding
FAMILY HISTORY
Mother –
(+) Diabetes Mellitus
(+) CVD infarct
Father –
(+) Hypertension, died at 40 y/o
due to heart attack
PERSONAL/SOCIAL HISTORY
• Works as a cook
• Lives with 3 children and their respective
spouses, and 3 grandchildren.
• No pets
• Non-smoker and occasional alcoholic
beverage drinker and denies use of illicit
drugs.
• Loves fried and salty foods, junk foods.
Drinks 2-3 cups of coffee per day.
• Hates exercise because she gets tired
easily.
REVIEW OF SYSTEMS
(-) palpitations, (-)
(-) easy fatigability :(-) epigastric pain (-) (-) muscle pain (-) joint
chest pain, (-)
(-) rashes,(-) pruritus pains (-) stiffness (-)
orthopnea hematemesis (-)
(-) dryness, (-) changes in
color dysphagia (-) heart limitations
CARDIO burn, (-) constipation
MUSCULO (-) easy bruising,
(-) bowel changes
GENERAL/ SKIN, (-) easy bleeding
HAIR, NAILS G.I. HEMA
RESPI NEURO
HEENT (-) cough, DOB, (-) seizures (-) MUSCULO
Hemoptysis
G.U. syncope , (-) loss
(-) heat/cold
(-) headache, (-) dizziness (-) eye of sensation (-)
pain (-) hearing changes (-) (-) hematuria, (-) tremors intolerance (-)
tinnitus(-) ear pain (-) ear polyuria, (-) oliguria, excessive sweating
discharges (-) nasal congestion (-) (-)dysuria, (-)
epistaxis (-) sore throat (-)
frequency, (-)
hoarseness, wears corrective
eyeglasses when reading discharge
PHYSICAL EXAM
Patient is awake, sitting

up, ambulates without
breathing difficulty, able
to speak in full sentences.
PHYSICAL EXAM
BP 160/110 mmHg HR 82 bpm

RR 21 cpm Temp 36.9°C
Wt 75.8 kg Ht 157 cm
Waist circumference: 85cm
O2sat: 98%
PHYSICAL EXAM
No active dermatosis, no
pallor, no jaundice, good
skin turgor, no clubbing of
fingernails, no cyanosis,
capillary refill time <2
seconds
PHYSICAL EXAM
Normocephalic, anicteric sclera,

pink palpebral conjunctiva, no
nasal congestion, pink oral
mucosa, pharynx without
exudates, no cervical
lymphadenopathy, no palpable
neck mass, no jugular vein
distention
PHYSICAL EXAM
No use of accessory muscles, no

alar flaring, no retractions, no
chest deformities, symmetric
chest expansion, clear and
equal breath sounds, resonant
percussion on all lung fields,
equal tactile and vocal fremitus
PHYSICAL EXAM
Adynamic precordium,
normal rate, regular rhythm,
no murmurs. PMI at 6th ICS
anterior axillary line, S1>S2
at the apex, S2>S1 at the
base
PHYSICAL EXAM
Flabby, (+) multiple striae, no

visible pulsations, normoactive
bowel sounds, soft, tympanitic,
(-) tenderness, no palpable
mass, no costovertebral angle
tenderness
PHYSICAL EXAM
No skin tags, no hemorrhoids,

no palpable mass, smooth
rectal mucosa, tight sphincter
tone, soft brown stools on
examining finger
PHYSICAL EXAM
Grossly normal, no limitations in

movement, no swelling, no
edema, no deformities, full
equal peripheral pulses
LABORATORY TESTS
CBC NV
Erythrocytes 4.6-6.2 5.82 Thrombocyte 150.0- 320
Hemoglobin 140-160 142 400.0
Hematocrit 0.40-0.54 0.48 MCH 27.0-31.0 29.2
Leukocyte 4.5-11.0 10.0 MCV 80.0-96.0 90.2
Diff Count MCHC 0.32-0.36 0.30
Neutrophils 0.37-0.72 0.561 RDW 11.5-14.5 13.2
0.20-0.50 0.234 MPV RNF 10.3
Lymphocytes
Monocytes 0.0-0.14 0.094
Eosinophils 0.0-0.06 0.001
Basophils 0.0-0.01 0.001
LABORATORY TESTS
TEST NV
(mmol/L)
Fasting Blood Sugar 4.10-5.90 7.20
Cholesterol Up to 5.2 8.9
LDL Up to 2.47 2.52
HDL Up to 1.03 0.08
Triglycerides Up to 1.69 2.50
Hemoglobin A1c 4.0-6.0 9.0%
Stat Capillary Blood 223
Glucose
LABORATORY TESTS
TEST NV
BUN 2.1-7.1 4.21 mmol/L
Creatinine 58-110 78 mmol/L

Total Protein 63-82 60.42
mmol/L
Albumin 35-50 32.30 g/L
Globulin 53.08 28.12 g/L
Sodium 135-148 138.7 g/L
Potassium 3.5-5.5 4.2 mmol/L
LABORATORY TESTS
URINALYSIS
Color Yellow
Character Slightly Turbid
Specific Gravity 1.020
pH 6.0
Sugar ++
Albumin +
Pus Cells 0-1
RBC 0-1
Mucus threads Plenty
Bacteria Plenty
12L ECG 1. Heart Rate: 53
bpm
2. Regular sinus
rhythm
3. Axis Deviation: -40
= Left axis
deviation
4. No LV
Enlargement
5. No significant ST
or T wave changes
CHEST XRAY
III. Salient
Features
SALIENT FEATURES
History
• 52 y/o, Female
• Difficulty Sleeping
• Intermittent nape pain, 3-4/10, during lunch
time, relieved by rest
• BP range: 140-160/90-100
• Difficulty falling asleep, 3-4 hours interrupted
• Multiple trips to bathroom at night
• Straw colored and bubbly urine
• Often thirsty
• Tingling sensation on fingertips
• Weight loss- 80kg last year to 75kg
SALIENT FEATURES
History
• History of Preeclampsia
• Family history of DM, CVD, Hypertension
• Occasional alcoholic beverage drinker
• Loves fried and salty foods, junk foods.
Drinks 2-3 cups of coffee per day.
• Gets tired easily
SALIENT FEATURES
P.E.
• BP 160/110
• Wt 75.8 kg ,Ht 157 cm
• Waist circumference: 85cm
• BMI= 30.7 (Obese)
• PMI at 6 th ICS anterior axillary line
SALIENT FEATURES
DIAGNOSTICS
• Elevated fasting blood sugar, HBa1c and stat
cbg.
• Elevated cholesterol, LDL, and triglycerides
• Hypoproteinemia, Hypoalbuminemia,
Hypoglobulinemia
• Glucosuria and Albuminuria
• ECG: Left Axis Deviation
• CXR: Cardiomegaly
IV. Approach
to Diagnosis
Multiple trips to bathroom at
night
• Low-volume bladder void

• Increased volume of nighttime
urinary output
• Sleep disturbance
(-) urgency
Female
UA: Pus cells: 0-1/hpf
(-) daytime sleepiness

(-) witnessed breathing
interruptions
(-) history of restless leg
Congestive Heart
Diabetes Mellitus Diabetes Insipidus
Failure
V. Differential
Diagnosis
RULE IN RULE OUT
• (+) Easy Fatigability • (-) Shortness of breath
• (+) Nocturia • (-) Orthopnea
• (+) Cardiomegaly • (-) Paroxysmal Nocturnal
• (+) PMI @ 6th ICS Dyspnea
• (-) Neck vein distention
• (-) crackles/rales
• (-) pleural effusion
• (-) ankle edema
• (-) Hepatomegaly
• (-) Ascites
RULE IN RULE OUT
• (+) Nocturia • (-) Frequency
• (+) Often Thirsty • (-) Enuresis
• (-) Excessive water intake
• (-) Hypernatremia
RULE IN RULE OUT
• (+) Nocturia • (-) polyphagia
• (+) Polydipsia • (-) polyuria
• (+) Peripheral Neuropathy
• (+) FH of Diabetes- mother
• (+) Obese
• (+) Elevated fasting blood
sugar, HBa1c and stat cbg
• (+) Glucosuria and
• (+) Albuminuria
Musculoskeletal
Strain
• Intermittent nape pain, 3-4/10, during
lunch time, relieved by rest
Hypertension
• BP range: 140-160/90-100
Stage II
Cardiomegaly
Primary Hypertension Secondary Hypertension
• Age
• Obesity
• Family History
• High Sodium
Diet
• Physical
inactivity
• Alcohol intake
RULE IN RULE OUT
• BP range: 140- • BUN & Creatinine
160/90-100 normal
• Nocturia • Urine Albumin: +1
(250-500mg)
• (-) Hematuria
• (-) Dysuria
• (-)oliguria
• (-) Flank pain
RULE IN RULE OUT
• BP range: 140- • (-) easy bruising
160/90-100 • (-) purple stretch
• Nocturia marks
• (+) Peripheral • (-) buffalo hump
Neuropathy • (-) thin brittle skin
• (+) Obese • (-) hirsutism
• (+) Elevated fasting • (-) proximal
blood sugar, HBa1c myopathy
and stat cbg • (-)skin
hyperpigmentation
RULE IN RULE OUT
• BP range: 140-
160/90-100 • Dry skin/moist skin
• Weight loss • Normal Heart rate
• Easy fatigability • (-) Heat/cold
intolerance
• (-) palpitations
• (-) bradycardia
• (-) constipation/
diarrhea
• (-) neck mass
VI. Initial
Impression
Diabetes Mellitus Type 2,
Uncontrolled
Hypertension Stage 2,
Uncontrolled
Dyslipidemia
Obese Class II
T/C Hypertensive Cardiomyopathy
VII. Case
Discussion
Hypertension
Whelton, P. et. al., May 2018.2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood
Pressure in Adults. A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.Journal of the American College of Cardiology.
Volume 71, Issue 19..
● Hypertension: leading
risk factor for death at the
global level.
● It increases steadily during
the first two decades of life.
● Associated with growth
and maturation in children
and adolescents.
Kasper, et. al. 2015. Harrison's Principle of Internal Medicine, 19th Edition, Section 5, Chapter 298,
McGraw-Hill Education.
● Men > women: average systolic
blood pressure during early
adulthood.
● Women > men: systolic blood
pressures at age 60 and older
● Widening of pulse pressure (the
difference between systolic and
diastolic blood pressure) beyond
age 60.
● Both environmental and genetic factors:
regional and racial variations.
● Obesity and weight gain: strong
independent risk factors for hypertension.
● High NaCl intake, Low dietary intakes of
calcium and potassium: risk of hypertension.
● Alcohol consumption, psychosocial stress,
and low levels of physical activity
● Renal Mechanism (Renin-angiotensin-aldosterone
system)
● Intravascular Volume
● Vascular Mechanism
● Neural Mechanism/Autonomic Nervous System
● Environmental and Genetic Factor
Taddei, S., et. al., December 2018. SC CardioMed (3 edn), Chapter:Epidemiology and pathophysiology of hypertension. Oxford
University Press.
Renin-Angiotensin-Aldosterone System
Figure 1. Main mechanisms involved in the pathophysiology of essential hypertension. DBP, diastolic
blood pressure; MBP, mean blood pressure; PP, pulse pressure; RAS, renin–angiotensin system; SBP,
systolic blood pressure.
Taddei, S., et. al., December 2018. SC CardioMed (3 edn), Chapter:Epidemiology and pathophysiology of hypertension. Oxford
University Press.
Elevated Blood Affects the Excess
pressure Blood-Brain pressure on
(BP of >180/120 Barrier the brain
mmHg)
Headaches Further
increases the
Dizziness Edema/Swelling
excess pressure
on the brain
Nausea
Confusion
Seizure
Weakness Blurring of Vision
Assarzadegan, F. et. al.,2013.Secondary headaches attributed to arterial hypertension.Iranian Journal of
Neurology.PubMed.
Elevated Blood Stresses the Neck Pain
pressure arteries (nape area)
Variation Description
White Coat Hypertension >140/90 mmHg (3 separate clinic-based

measurement) and <140/90 mmHg (2 non-clinic-
based measurements) in the absence of target
organ damage.
Resistant Hypertension Office BP >/= 130/80 mmHg and with >/= 3 drugs at
optimal doses (including diuretics) or Office BP
<130/80 but requires >/= 4 drugs
Orthostatic Hypertension Fall in SBP >20 mmHg or in DBP >10 mmHg within3
minutes of assuming upright posture from a supine
position
Masked Hypertension Normal or even low BP, with evidence of
hypertensive end organ damage. Consider severe
PAD.
HYPERTENSIVE HYPERTENSIVE
URGENCY EMERGENCY
BLOOD SBP >180 mmHg or SBP >180 mmHg or
PRESSURE DBP >120 mmHg DBP >120 mmHg
TARGET ORGAN PRESENT
DAMAGE NONE (microvascular: retinopathy,
nephropathy, vascular dementia and
Macrovascular: stroke and MI)
MANAGEMENT Reinstitute or intensify Admit to ICU and

oral antihypertensive manage based on the
drug therapy and presence of compelling
arrange close follow- conditions
up
It is to facilitate CVD risk
factor profiling, establish a
baseline for medication use,
and screen for secondary
causes of hypertension.
Optional tests: Target organ

damage.
Serum sodium and

potassium levels: diuretic or
RAS blocker titration.
Serum creatinine and
urinary albumin: Markers of
CKD progression.
Thyroid-stimulating hormone:
detect hypothyroidism and
hyperthyroidism (2 remediable
causes of hypertension)
Diagnosing and Managing Hypertension in Adults, American Heart Association, 2018
Whelton, P. et. al., May 2018.2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in
Adults. A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.Journal of the American College of Cardiology. Volume 71, Issue 19..
de Boer, I.H., et. al., Diabetes and Hypertension: A Position
Statement by the American Diabetes Association.Diabetes
Care.
● Heart disease: most common cause of
death in hypertensive patients; results of
structural and functional adaptations.
● Left ventricular Hypertrophy: increased
risk for CHD, stroke, CHF, and sudden
death.
● Diastolic dysfunction: early
consequence of hypertension-related
disease; exacerbated by LVH and
ischemia.
● Stroke: second most frequent cause
of death.
● Elevated blood pressure: strongest
risk factor for stroke (85%: Infarction).
● Increased systolic blood pressure:
Age > 65 years.
● Impaired cognition and Dementia:
aging population
Kasper, et. al. 2015. Harrison's Principle of Internal Medicine, 19th Edition, Section 5, Chapter 298, McGraw-Hill Education.
● Hypertensive Encephalopathy:
Severe headache, nausea, and
vomiting (often a projectile nature),
focal neurologic signs, and
alteration of mental status.
● Untreated: progress stupor, coma,
seizures, and death within hours.
Kasper, et. al. 2015. Harrison's Principle of Internal Medicine, 19th Edition, Section 5, Chapter 298, McGraw-Hill Education.
Renal injury and ERSD
●Renal risks: systolic blood pressure
●Black men greater risk than white
men for developing ERSD
●Artherosclerotic disease
secondary to long-standing
elevated blood pressure
Non-pharmacologic:
Lifestyle Modification
● Weight loss
● Low Fat, Low Sodium Diet
● Enhanced intake of
Potassium
● DASH Diet
● Physical activity
Non-pharmacologic:
● Daily BP monitoring
● Follow-up after 2
weeks for treatment
adjustment
Pharmacologic:
○ Hydrochlorothiazide 12.5mg, OD
○ Amlodipine 5mg, ODHS
Diabetes
Mellitus
Type II
● This is a disease that refers to a group of
common metabolic disorders that share
the phenotype of hyperglycemia.
● Factors contributing to hyperglycemia:

○ Reduced insulin secretion
○ Decreased glucose utilization
○ Increased glucose production
Harrison’s Principles of Internal Medicine 19th ed.
● Causes secondary
pathophysiologic changes
in multiple organ systems

● Type 1 DM
○ Abnormal glucose
homeostasis

● Type 2 DM
○ Insulin Resistance
○ Impaired insulin secretion
○ Increased glucose production
○ Preceded by abnormal glucose
homeostasis classified as
Impaired Fasting Glucose (IFG) or
Impaired Glucose Tolerance (IGT)

Unite for Diabetes CPG 16th ed, 2014 ADA Standards of Care, 2020
Harrison’s Principles of Internal Medicine 19th
WHO Diabetes country profiles 2016
https://psa.gov.ph/vital-statistics/id/138794
WHO Diabetes country profiles
2016
Unite for Diabetes CPG 16th ed, 201

● Balance between hepatic glucose
production and peripheral glucose utilization.
● Insulin is the most important regulator of this
equilibrium
● In fasting states, glucagon rises with glucose
production increased via promoting the
mobilization of stored precursors.
● In the post prandial states, a rise in insulin
leads to the reversal of the processes
https://socratic.org/questions/how-is-gluconeogenesis-related-to-glycolysis
● Glucose is the key regulator of insulin
secretion by the pancreatic beta cell.
● Insulin synthesis is stimulated when
glucose levels exceed 3.9 mmol/L
(70mg/dl)
● Glucose phosphorylation by
glucokinase is the rate limiting step
that controls insulin secretion
https://www.researchgate.net/figure/Pathophysiology-of-type-2-diabetes-mellitus-
T2DM_fig1_328964882
Harrison’s Principles of Internal Medicine 19th ed
ADA Standards of Care for diabetes, 201
9 in plate
Starch Protein
Vegetables
Exercise
● Exercise should be moderate intensity
● Total of 150 hours per week with no interval longer than 3 days
● 30 mins per day
● (1) monitor blood glucose before, during, and after exercise;
● (2) delay exercise if blood glucose is >14 mmol/L (250 mg/dL) and ketones are
present;
● (3) if the blood glucose is <5.6 mmol/L (100 mg/dL), ingest carbohydrate
before exercising;
● (4) monitor glucose during exercise and ingest carbohydrate to prevent
hypoglycemia;
● (5) decrease insulin doses (based on previous experience) before exercise and
inject insulin into a nonexercising area;
● (6) learn individual glucose responses to different types of exercise and
increase food intake for up to 24 h after exercise, depending on intensity and
duration of exercise.
● Involves plasma glucose measurements.
● Self-monitoring of blood glucose is standard
care of DM management
○ Frequency should be individualized
○ If patient is taking insulin, three or more

times a day of routine monitoring should be
done
● Monitoring of HbA1c is standard method of
assessing long term control of diabetes.
○ Should be pointed out in patients as part of

standard diabetes care.

Harrison’s Principles of Internal Medicine 19th
Dyslipidemia
is a group of disorders of
lipoprotein metabolism
regarded as primary risk
factors for atherosclerotic
disease, especially coronary
heart disease.
Characteristics of Dyslipidemia
Elevated Triglycerides
Elevated Total Cholesterol
Elevated LDL
Reduced HDL
These may occur singly or in clusters of 2 or 3.
2015 Updated Clinical Practice Guidelines for the Management of Dyslipidemia in the Philippines
20th Edition Harrison’s Principles of Internal Medicine, Part 12, Section 3, Topic 400, Disorders of Lipoprotein Disorders, 2889
PREVALENCE
Epidemiology
33%
Of all Deaths, 2014
WHO-NCD
continues to increase
KEY NUMBERS
Other risk factors Prevalence

Diabetes 5.4%
Obesity 6.8%
Hypertension 22.3%
Smoking 25.4%
Insufficient exercise 45.2%
important lower threshold for

preventive care.
PATHWAY
ENDOGENOUS
PATHWAY
EXOGENOUS
Hepatic
Lipase
20th Edition Harrison’s

Principles of Internal
Medicine, Part 12, Section
3, Topic 400, Disorders of
Lipoprotein Disorders,
2891
PATHWAY
ENDOGENOUS
PATHWAY
EXOGENOUS
Hepatic
Lipase
REVERSE
CHOLESTEROL
TRANSPORT
Lipoprotein Function / Description
Chylomicron • Delivers dietary triglycerides to peripheral tissues
• Delivers cholesterol to the liver in the form of Chylo.
remnants
VLDL • Delivers hepatic triglycerides to peripheral tissues
• Secreted but the liver
IDL • Formed in the degradation of VLDL
• Delivers Triglycerides and cholesterol to the liver
LDL • Delivers hepatic cholesterol to peripheral tissues
• Formed by LPL from VLDL in the peripheral tissues
HDL • Mediates reverse cholesterol transport (from Periphery to
the Liver)
• Important independent predictor of increased
cardiovascular risk
20th Edition Harrison’s Principles of Internal Medicine, Part 12, Section 3, Topic 400, Disorders of Lipoprotein Disorders, 2889-2892
Secondary causes of dyslipidemia:
1. Carbohydrate diet
2. Alcohol
3. Obesity and Insulin Resistance - excessive hepatic production;
decreased LPL activity
4. Cushing’s Syndrome - glucocorticoid excess
5. Hypothyroidism – reduced hepatic LDL receptor; decreased
clearance
6. Chronic Kidney Disease - clearance is reduced in the circulation
7. Liver Disorders
8. Drugs
20th Edition Harrison’s Principles of Internal Medicine, Part 12, Section 3, Topic 400, Disorders of
Lipoprotein Disorders, 2889-2898
ABOUT THE DISEASE
Plasma Full LDL-C using VLDL

Lipid Levels Fridewald formula Formula: TG/5
With 12 hours Fasting LDL-C = total cholesterol Not applicable if,
– (TG/5) – HDL-C TG >400mg/dL
Lipoprotein Disorders, 2900
ABOUT THE DISEASE
Social, Medical, and

Family History
Obtain Fasting
Glucose
Rule out Secondary
Causes
Class of Lipoproteins Urine Protein and
Increased / Decreased Serum Creatinine
Liver Function Tests
TSH
Lipoprotein Disorders, 2900
≥ 150 mg/dL
Borderline: 200-239 mg/dL

High: ≥ 240 mg/dL
Borderline: 130-159 mg/dL
High: ≥ 160 mg/dL
Low: < 40 mg/dL
156
157
Lifestyle
Modification Pharmacologic
(Diet, Exercise, Interventions
Smoking Cessation)
Low fat
 Reduction of Saturated Fat to <7%
 Reduction of Trans Fat to <1%
Diet Low cholesterol diet

 Reduction of Cholesterol to <200 mg/day of
the Total Calorie Intake
Foods rich in fruits and vegetables
2018 ACC/AHA Guidelines on the Management of Blood Cholesterol

“Pinggang
Pinoy”
Diet FNRI, 2014
Approximately 150 minutes of
moderate- to high intensity exercise
per week.
 Reduce LDL-C by 0.45%
 Reduce Triglycerides by 0.23%
 Increase HDL-C by 0.02%.
5 sessions of 30
mins. of moderate-
high intensity exercise  Reduce major acute coronary events by
/ week = For Better 25%,
COMPLIANCE  Reduce non-fatal myocardial infarction by
71%
The ASCVD Risk Calculator is
to estimate a patient’s 10-year
ASCVD risk.
4 Benefit Groups of Statin Therapy (1st Line
Treatment)
Secondary Prevention in Patients with Clinical ASCVD
1 •ACS/Hx of MI; Stable/Unstable Angina; Coronary/Arterial Revascularization; Stroke/TIA
Primary elevations of LDL-C >190mg/dL (>4.9mmol/L)

2 (no secondary cause identified such as diet, drugs, diseases)
40-75 years old+ LDL 70-189 mg/dL + DM w/o Clinical ASCVD

3 (For Primary Prevention)
40-75 years old+ LDL 70-189 mg/dL + Estimated 10 year ASCVD

Risk >7.5% w/o Clinical ASCVD or DM
4 (For Primary Prevention)
`
Pharmacologic Intervention
2018 ACC/AHA Guidelines on the

Management of Blood Cholesterol
`
Primary elevations of LDL-C

>190mg/dL (>4.9mmol/L)
(no secondary cause

identified such as diet, drugs,
diseases)

`

`
Pharmacologic Intervention
4th Statin
Benefit Group

- First line tx and most potent drugs that lower LDL cholesterol.

“Statin-associated
Side Effects to Statin
Intolerance”

 Reassess at 4 to 12 weeks with a fasting or non-fasting lipid
test.
 check for statin intolerance
 retest every 3 to 12 months if needed
 reduction in LDL-C (rather than total cholesterol)
 Routine measurements of Creatine Kinase and
Transaminase levels are not useful tests for patients taking
statins.

 A state of excess adipose tissue
mass.
 Defined by assessing its linkage to
morbidity or mortality.
20th Edition Harrison’s Principles of Internal Medicine, Part 12, Section 3, Topic 395, Evaluation and Management of Obesity, 3843
BMI = weight (kg) / height (m)2 or weight (lb) / height (in)2 x 703
20th Edition Harrison’s Principles of Internal Medicine, Part 12, Section 3, Topic 395, Evaluation and Management of Obesity, 3844
174
Metabolic Sx:
 BMI >40 kg/m2 (BMI >37.5 kg/m2 in Asian
Americans)
 BMI 35.0–39.9 kg/m2 (32.5–37.4 kg/m2 in Asian
Americans) who do not achieve durable weight loss
and improvement with nonsurgical methods
American Diabetes Association Standards of Medical Care in diabetes—2020
VIII. Plan
Subjective Objective Assessment Plan
-5 mo. history of difficulty Wt: 75.8kg Ht: 157cm Diabetes Mellitus •DM Diet
falling asleep BMI: 30.7 (Obese Class Type II, •Therapeutics:
-able to sleep only 3-4 II) Uncontrolled -Metformin 500mg/Tab
interrupted hours at night, BID
and had multiple trips to -Vitamin B-Complex
the bathroom to pee FBS: 7.20 •Supportive:
-urine to be straw colored Triglycerides: 2.50 -For Patient Education
and somewhat bubbly HbA1c: 9.0% -For Medical Nutrition
-often feels thirsty CBG: 223 Therapy
-tingling sensation on her UA: -For daily foot
fingertips Sugar: ++ examination
- Weight loss: 80kg to Albumin: +
75kg in 1 year
- Family History: Mother-
DM type II
Anticipative Care
Lifestyle Changes • Moderate weight loss of >5% Body weight- (Target: 70-72 kg)
• 150 min/week moderate intensity aerobic exercise, spread over at
least 3 days/week.
• DIET recommended: (1,200-1,500 kcal/day, 500–750 kcal/day energy
deficit.) Mediterranean, DASH, and plant-based diet
• Orlistat 60mg TID if financially capable
Retinopathy • Refer to ophthalmology service for Initial screening (repeat annually)
Foot Care • Daily foot care
• comprehensive foot evaluation at least annually
• use of appropriate therapeutic footwear ( well-fitted walking shoes or
athletic shoes that cushion the feet and redistribute pressure)
-6 month history of BP: 160/110 Hypertension •Low salt, low fat diet
intermittent PMI at 6th ICS stage II, •Diagnostics:
constricting nape pain, anterior axillary line uncontrolled -For 2d Echo, TSH
3-4/10, usually during ECG: Left Axis •Therapeutics:
lunch time, Deviation -Losartan 50mg, OD
spontaneously relieved CXR: Cardiomegaly -Amlodipine 5mg, ODHS
by rest and nap •Supportive:
-Daily BP monitoring
-Refer to Ophthalmology
-BP range of 140- department for further
160/90-100 evaluation and
management
-Follow-up after 2 weeks
for treatment adjustment
Cholesterol: 8.9 Dyslipidemia •DASH Diet
LDL: 2.52 •Diagnostics:
Triglycerides: 2.50 - For baseline ALT, AST
- Repeat Lipid Profile after
4 weeks
•Therapeutics
-Atorvastatin 40mg tab
ODHS
•Supportive:
-Physical activity, 5 sessions
of 30 minutes per week
IX. Final
Diagnosis
Diabetes Mellitus Type 2,
Uncontrolled
Hypertension Stage 2,
Uncontrolled
Dyslipidemia
Obese Class II
T/C Hypertensive Cardiomyopathy
● Whelton, P. et. al., May 2018.2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA
Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. A
Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice
Guidelines.Journal of the American College of Cardiology. Volume 71, Issue 19..
● Kasper, et. al. 2015. Harrison's Principle of Internal Medicine, 19th Edition, Section 5, Chapter 298, McGraw-
Hill Education.
● Taddei, S., et. al., December 2018. SC CardioMed (3 edn), Chapter:Epidemiology and pathophysiology of
hypertension. Oxford University Press.
● Grundy SM, Stone NJ, Bailey AL, et al. 2018
AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of
blood cholesterol: a report of the American College of Cardiology/American Heart Association Task Force on
Clinical Practice GuidelinesAUTHOR (YEAR).
● American Diabetes Association; Standards of Medical Care in Diabetes 2020.pdf

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Intern’s

To be able to enumerate differential diagnoses

To discuss the appropriate management of

• intermittent episodes of constricting

• intermittent episodes of nape

• still had difficulty in

• No history of PTB treatment

HAIR, NAILS G.I. HEMA

Patient is awake, sitting

BP 160/110 mmHg HR 82 bpm

Normocephalic, anicteric sclera,

No use of accessory muscles, no

Flabby, (+) multiple striae, no

No skin tags, no hemorrhoids,

Grossly normal, no limitations in

Creatinine 58-110 78 mmol/L

• Low-volume bladder void

(-) daytime sleepiness

White Coat Hypertension >140/90 mmHg (3 separate clinic-based

MANAGEMENT Reinstitute or intensify Admit to ICU and

Optional tests: Target organ

Serum sodium and

● Factors contributing to hyperglycemia:

Harrison’s Principles of Internal Medicine 19th ed.

Harrison’s Principles of Internal Medicine 19th ed.

Harrison’s Principles of Internal Medicine 19th ed.

Unite for Diabetes CPG 16th ed, 201

○ Frequency should be individualized

○ If patient is taking insulin, three or more

○ Should be pointed out in patients as part of

Harrison’s Principles of Internal Medicine 19th ed.

Other risk factors Prevalence

important lower threshold for

20th Edition Harrison’s

Plasma Full LDL-C using VLDL

Social, Medical, and

Liver Function Tests

Borderline: 200-239 mg/dL

Low: < 40 mg/dL

Diet Low cholesterol diet

2018 ACC/AHA Guidelines on the Management of Blood Cholesterol

Primary elevations of LDL-C >190mg/dL (>4.9mmol/L)

40-75 years old+ LDL 70-189 mg/dL + DM w/o Clinical ASCVD

40-75 years old+ LDL 70-189 mg/dL + Estimated 10 year ASCVD

2018 ACC/AHA Guidelines on the

Primary elevations of LDL-C

(no secondary cause

2018 ACC/AHA Guidelines on the

2018 ACC/AHA Guidelines on the Management of Blood Cholesterol

2018 ACC/AHA Guidelines on the

2018 ACC/AHA Guidelines on the Management of Blood Cholesterol

2018 ACC/AHA Guidelines on the

2018 ACC/AHA Guidelines on the Management of Blood Cholesterol

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