Ambulatory Care

Parameter/ Anti-coagulation DM HPT Hyperlipidemia COPD Asthma

Diseases therapy

Sign& Symptoms S&S: unusual thirst, Persistently elevated Characterized as S&S: chronic cough Chronic inflammation
Risk factors frequent urination, delayed arterial blood elevated total and expectoration on disorder of airways
wound healing, tired & pressure cholesterol, LDL, TG, most days for at least lead to
sleepy, nausea, blurred HDL or combination 3 months a year in
vision, weight loss, Usually asymptomatic of aforementioned. two consecutive years Recurrent S&S:
polyphagia ( eating a lot of • Wheezing
food) Most of patient Clinical presentation: • Breathlessness
asymptomatic • Characterized by • Chest tightness
Risk factors: persistent airflow • Cough
• Family hx S&S: chest pain, obstruction, which particularly at
• Obesity palpitation, is slowly night, early
• Age 40 orolder sweating, anxiety, progressive morning or
• Race/ethnicity SOB • Chronic bronchitis associated with
• Hx of glucose • Emphysema ( exercise
intolerance Risk factors:
• HTN • Family Hx Risk factors: Triggered factors:
• Hx of gestational • Chronic dx (DM, • Cigarette smoking • Cold air
diabetes renal failure, • Passive smoking • Exercise
• Hx of giving birth to nephrotic • Air pollution esp • Upper respiratory
baby over 10 lbs syndrome, SO2 and infection
• HDL ≤ 35 mg/dL hypothyroidism) particulates • Cigarette smoke
• Triglyceride level ≥ 250 • Alcoholism • Poverty and low • Respiratory
mg/dL • Smoking socioeconomic allergens
• Obesity status • Bronchial
• Unhealthy diets • Viral infection provocation with
leading to airway allergen
hyperresponsiven • Atmospheric
ess pollution
• Occupational
exposure (e.g.
cadmium and
silica)
 • Genetic factor
(e.g. alpha 1-
antitrypsin
deficiency)

Goal of treatment ü Reduce chance ü Maintain target blood ü Overall goal is to ü Lower total and ü To improve sx and ü Prevent chronic
of abnormal glucose reduce morbidity LDL cholesterol QOL and troublesome
clotting from ü Prevent diabetes and mortality by to reduce risk of ü To reduce symptoms (e.g.
forming in the complication the least intrusive first or recurrent progressive coughing or
blood. mean possible. events such as decline in lung breathlessness in
MI, angina, function night, in early
ü Prevent ü JNC-8 guidelines heart failure, ü To prevent and morning, or after
formation and recommend goal ischemic stroke, treat extertion)
progression of BP less than or peripheral complications ü Maintain normal
blood clots. 140/90 mm/Hg arterial dx. ü To prolong pulmonary
for most patients, survival function
less than 140/90 ü To reduce the ü Maintain normal
for adult patient number of activity levels
with diabetes or exacerbations and ü Prevent recurrent
chronic kidney need for hospital exacerbations of
disease, less than admissions asthma and
150/90 mm/Hg minimize need
for patients older for emergency
or equal to 60 department visits
years old. or
hospitalizations
ü Hypertensive ü Provide optimal
emergencies pharmacotherapy
with minimal or
Require no adverse
immediate BP effects
reduction to limit ü Meet patient’s
new or and families’
progressing expectations of
target-organ and satisfaction
damage. Initial with asthma care
reduction to 25%
within minutes to Chronic asthma
 hours; reduced ü Restore normal
toward 160/100 or best possible
to 110 within the long term airway
next 2-6 hours; function
additional gradual ü Reduce morbidity
decrease toward and prevent
goal BP can be mortality
attempted after
24-48 hours.

Rx medication 1. Warfarin 2mg 4. Biguanides 1. ACE inhibitor 1. HMG CoA Bronchodilators Use lowest effective
2. Orfarin 3 mg (weight loss) 2. ARB reductase (mainstay) dose of convenient
3. Orfarin 5 mg 5. Secretagogues SU 3. CCB inhibitors (first a. Anticholinergics medications
(caution in allergic to 4. Thiazide diuretics line for high LDL (Ipratropium minimizing short and
SU; SU are highly 5. Beta blockers lvl) bromide) long term side effects
protein bound; weight 2. Fibrates ( first b. Beta-2 agonist
gain) line tx for high (salbutamol) Bronchodilators
6. Secretagogues non-SU TG; TG > c. Methylxanthines (treat sx of asthma)
(short half-life than SU; 5.7mmol/L) d. Beta-2 agonist
take within 10 mins 3. Ezetimibe Use of CCS not yet (salbutamol)
before meal) (second line tx, been established in e. Anticholinergics
7. Thiazolidindediones (x reduce COPD. (Ipratropium
combine w insulin) absorption of bromide)
8. Alpha-glucosidase cholesterol Antibiotic f. Methylxanthines
inhibitor (taken w main through GIT) (ampicillin/amoxicillin)
meal) 4. Bile acid resins when infection Anti-inflammatory
9. Incretins (DPP-4 (cholestyramine) presence drug
inhibitor & GLP-1 5. Niacin a. CCS (prophylactic
analogue) drug)
10. SGLT-2 (lower risk of (e.g.
hypo; not used with beclomethasone
loop diuretic) dipropionate;
11. Insulin budesonide)
b. Sodium
cromoglycate(ma
st cell stabilizer)
Lab/Investigation Target forT2DM Lipid profile -PFTs
o Total plasma -asthma severity
Glycaemic control cholesterol (<
Fasting : 4.4-6.1 mmol/L 200mg/dL)
Non-fasting: 4.4-8.0 o HDL
A1C : ≤6.5% (younger o TG
age,healthier) o LDL
7.1-8.0% (co- Ø High risk of CVD
morbidities: renal failure, and CHD: LDL<
heart failure, short life 2.6mmol/L
expentancy, prone to Ø Intermediate
hypoglycaemia) risk: LDL<3.4
mmol/L
Ø Low risk: LDL<
Lipids 4.1mmol/L
TG: ≤ 1.7 mmol/L
HDL: ≥ 1.1 mmol/L
LDL : ≤ 2.6 mmol/L

BP: ≤135/75 mm Hg

Monitoring • Blood sugar • Evaluate BP • Spirometry Pulmonary function

• HbA1c response 2-4 Mild COPD: FEV1> 70% tests (PFTs)
• Lipohypertrophy weeks after of predicted value • Spirometry
(insulin) initiating therapy. Moderate COPD: FEV1 (measure lung
• Complication from DM Once goal BP between 50% to 70% volumes and
• Sx of hypoglycaemia: values are Severe COPD: FEV1 < airflow dynamics)
ü Tremer obtained, monitor 5% FEV1: 75% of
ü Palpitation BP every 3-6 predicted normal of
ü Sweating months. • Chest radiography 4L (normal)
ü Giddiness (e.g. large FVC: 75% of a
ü Hunger • Monitor patient pulmonary predicted normal of
 ü Confused sign and arteries, vascular 3.2L (normal)
symptoms of attenuation) Measurement :
progressive FEV1/FVC
target-organ dx. • Reversibility of
airflow • Peak Expiratory
• Monitor adverse obstruction can Flow Rate
drug effects. be demonstrated (maximum flow
either by rate that can be
• Assess patient Ø A bronchodilator produced during
adherence with challenge forced expiration
regimen regularly. Ø A trail of CCS for following a deep
two weeks with breath to full
spirometry before inspiration)
and after
Ø A positive • Asthma severity
spirometric (NIH)
response to
bronchodilators or • Global Initiative
CCS when the for asthma
FEV1 increases by (GINA)
15% of the Ø Daytime sx
baseline value. Ø Limitation of
activities
Ø Nocturnal
sx/awakening
Ø Frequency of
using reliever
Ø Exacerbation
Ø Lung fuction

DM

*Insulin: rapid acting (Novolog, Humalog) 15 mins before meal tds

Short acting (Actrapid) 30 mins before meal tds

Intermediate (Insulatard, NPH Humulin, Novolin) pre-breakfast/ pre-bed (usually pre-bed)

 Long (Determir, Glargine, Lantus, Levemir) same time every day (once daily)

Premixed (Mixtard, Novomix) (pre-breakfast/ pre-dinner) OD or BD

*SU- CI in pregnant women

*Biguanide- CI in pt with renal failure and liver dx (↑risk of lactic acidosis)

*TZD- CI in pt with congestive heart failure, pregnant/breast feeding, woman, child

*alpha glucosidase inhibitors +SU will causes hypoglycemia, +metformin can disrupt metformin absorption

Asthma & COPD

Asthma COPD
Definition A chronic inflammatory disorder of the airways Dx state characterized by airflow
limitation that is not fully reversible
Onset Early in life Midlife
Airflow limitation Widespread through variable; often reversible Usually progressive and associated with
spontaneously or with treatment abnormal inflammatory response to
particles or gases

*Beta blocker CI in all asthmatics

*Avoid aspirin and NSAIDs which known to precipitate asthma

*Spirometry test lung function

*Anti-cholinergic is first line in COPD because can used for both short- and long-term relief of symptoms. Long term help in breathing problem. Inhaled anticholinergic can
help to improve lung function.