Recap our top pearls from recent shows on hypertension, sarcoidosis, and seizure. It’s Tales from the Curbside #3(TFTC #3)!, our monthly series providing a rapid review of recent Curbsiders episodes.
Note: No CME for this mini-episode but visit curbsiders.vcuhealth.org to claim credit for #254, #256, and #257.
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Produced by Deb Gorth with graphic by Edison Jyang
BP goals boil down to the “acceptable” and the “ideal” typically <140/90 and <130/80. Dr Vongpatanasin recommends using validatebp.org to find a BP cuff. Arm > wrist cuff. Check twice daily for 7 days to confirm the diagnosis. She recommends that patients average multiple readings (e.g. 2-3 readings in a row spaced by 1 min) each time they check.
Caution spironolactone in men (sexual side effects and gynecomastia, dec libido, ED).
Home BP readings tend to be lower than office readings, especially for in-office readings above 130/80. Remember that masked hypertension (normal clinic BP, but high home BP) and white coat hypertension (normal home BP and high clinic BP) both confer some cardiovascular risk, though less than that of sustained hypertension (BP high in all settings).
Consider the combo pill! Dr. Vongpatanasin taught us that one large health system prescribes lisinopril-hctz 20-25 mg tabs and patients take half a tab, full tab, two tabs based on the severity of their hypertension.
Produced by Deb Gorth with graphic by Edison Jyang
We often find it incidentally when imaging asymptomatic patients. Sarcoidosis should be considered in patients with a history of multiple courses of antibiotics for non-resolving infections. Also, consider it in the patient with a history of unexplained syncope and palpitations. ACE levels are not a useful test for the diagnosis of sarcoidosis due to poor sensitivity and specificity.
“The diagnosis of sarcoidosis is arbitrarily made when the statistical likelihood of alternative diagnoses becomes too small to warrant further investigation”
Dr. Jonathan Boltax
Initial workup: Full history and physical plus a CXR, full PFTs, eye exam, EKG, and bone labs (alk phos, 25-OH vitamin D, 1,25-OH vitamin D, and Calcium). Consider a high-resolution CT scan of the chest. Further testing may include Cardiac MRI or a full-body PET scan.
Steroids are often started at a dose of 20-40 mg daily and tapered over months. Dr. Boltax notes that some patients come off steroids entirely. Others require maintenance doses with adjuvant immunomodulators added if patients cannot get below 10 mg prednisone daily. Consider pneumocystis prophylaxis for patients on at least 30 mg of prednisone for more than 30 days.
Produced by Beth Garbs Garbitelli and Paul Williams
In a rapid response for the patient having a seizure, don’t put something in their mouth! Lay them on their side. Move them away from harmful objects. Time the seizure. Mind your ABCs. Call 911. Video the event if possible.
Graphic by Beth Garbitelli
Counsel patients about seizure precautions: Avoid ladders. Always have supervision around water. Consider an epilepsy safe pillow. No driving for 3-6 months or when seizures uncontrolled. Common triggers include: poor sleep, alcohol use, and drugs (antibiotics, tramadol, bupropion).
Graphic by Beth Garbitelli
Monitor for medication side effects with routine labs (including drug levels annually) and vitamin D levels for patients on antiepileptic drugs (AEDs) that are inducers of cytochrome p450. Be ever mindful of comorbid mood disorders (approx. 20-50% prevalence). Patients with seizures are 3.5 to 5.8 times more likely to die from suicide.
Listeners will review tops pearls from recent curbsiders episodes
After listening to this episode listeners will…
Drs. Watto and Williams report no relevant financial disclosures.
Watto MF, Williams PN. “#265 TFTC #3: Hypertension Update, Sarcoidosis, Seizures”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date March 31, 2021.
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