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■ ACE mhílbái:<'>r diabetes (renal protection), impotence with other ; ¡ucdh'jnons

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'. Elcctn .iytk- pi-oMterns, pregnane); göot '.■:""'■."■'

' ■■ ■ Diabetes, 'astlima/chronic, obstructive pulmonary ' "disease, pregiiaiicy, bradycardui/heait : ■ -

.' Éeçtroly'(e 'prabkii!.is-, pregnancy, renovascular . : hypertension (may- cause aôitè renal failure).' .

ACÉ. inhibitors1 aïe -fifst- line -ageius-fbr congestive heart faihire, beeayise. they Have beeir shows '.to.redacte t'noití'lity, Asiy patient "with". ■•.';f¡yp«teBSíc6tt failure, (and fcoy: patient wftft' congestive "heart Mure) ShöuM' i* pué oh' aaACE ¡«hitótor ;

Hypertensive emergencies: usually occur when blood pressure is > 200/100 mmHg. Defined as hypertension with acute end-organ damage (i.e., severe hypertension plus one of the following: acute left ventricular failure, unstable angina, myocardial infarction, or encephalopathy; symptoms include one or more of the following: headaches, mental status changes, vomiting, blurry vision, dizziness, papilledema). Hypertensive emergencies are an exception to the rule of measuring blood pressure 3 times before treating! Use nitroprus.side, nitroglycerin, diazoxide, or labetalol emergen tly.

Secondary hypertension: clues include onset before 30 or after 55 years of age and other suggestive history or lab values. In a young woman, the most common cause is birth control pills (discontinue them), followed by renovascular hypertension due to fibrous dysplasia (renal bruit: use intravenous pyelogram or arteriogram for diagnosis; treat with balloon dilatation or angioplasty). In a young man, think of excessive alcohol intake or exotic conditions (pheo-chromocytoma, Cushing's syndrome, Conn's syndrome, polycystic kidney disease), in elderly patients with new-onset hypertension, think renovascular hypertension due to atherosclerosis (renal bruit; ACE inhibitor precipitates renal failure). If yon suspect secondary hypertension (95% of cases of hypertension are essential, primary, or idiopathic), remember the following hints and tests to order:

1. Pheochromocytoma: urinary catecholamines (vanillylmandelic acid, metanephrine) plus intermittent severe hypertension, dizziness, and diaphoresis

2. Polycystic kidney disease: flank mass, family history, elevated blood urea nitrogen, creatinine

3. Cushing's syndrome: dexamethasone suppression test or 24-hr urine Cortisol level

4. Renovascular hypertension: intravenous pyelogram or angiogram; look for bruit

5. Conn's syndrome: high aldosterone, low renin

6. Coarctation of the aorta: upper extremity hypertension only, unequal pulses, radiofeinoral delay, associated with Turner's syndrome, rib notching on x-ray

Note: lowering blood pressure lowers risk for stroke (hypertension is the most important risk factor), heart disease, myocardial infarction, renal failure, atherosclerosis, and dissecting aortic aneurysm. Coronary disease is the most common cause of death among untreated hypertensive patients. Don't forget to treat isolated systolic or diastolic hypertension if it persists.

Note: Nitroprusside dilates arteries and veins, whereas nitroglycerin is a venodilator only and other medications are arterial dilators only (hydralazine, alpha [ antagonists, calcium channel blockers). Venodilators reduce preload, whereas arterial dilators reduce afterload (nitroprusside does both).

Universal screening is generally not recommended . Screening in patients who are obese, > 45 years old, have a positive family history, or are members of certain ethnic groups (black, American Indian, Hispanic) is more accepted but not uniformly.

Classic symptoms of diabetes are polydipsia, polyuria, polyphagia and weight loss. Diagnosis is made by a fasting plasma glucose > 126 mg/dl (after an overnight fast) or a random glucose (no fasting) > 2.00 mg/dl. If the patient has classic symptoms, one measurement is enough to confirm a diagnosis, but in an asymptomatic patient, the test should be repeated. Rarely, an oral glucose tolerance test (OGTT) is done and DM is diagnosed when levels > ,'00mg/dl are reached within or at 2 hours after a 75-gm glucose load is administered orally.

The goal of treatment is to keep postprandial glucose < 200 mg/dl and fasting glucose <130 mg/dl. Stricter control results in too many episodes of hypoglycemia (look for symptoms of sympathetic discharge and mental status changes)

Important points:

1. Remember the importance of C-peptide in distinguishing between too much exogenous insulin (low C-peptide with accidental overdose in a diabetic or factitious disorder) and. an insulinoma (high C-peptide).

2. Because IV contrast agents can precipitate acute renal failure in diabetics and other renal patients, you should use contrast only if absolutely necessary. Make sure that the patient is well-hydrated before using contrast agents in diabetics and renal patients to prevent renal damage,

3. Diagnosis of diabetic ketoacidosis (type I diabetes mellitus) req uires hyperglycemia, hy~ perkctonemia, and metabolic acidosis. Treatment involves fluids, IV regular insulin, and potassium and phosphorus replacement. Do not use bicarbonate unless the pH is < 7.0. Search for the cause, which often is infection. The mortality rate is about 10%.

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