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VOLUME 1 ISSUE 3 CASE SW	SW is a 49-year-old man who presents for an employment physical. He has not seen a physician in the last 10 years, but considers himself healthy. He has had no hospitalizations as an adult.
PHYSICAL EXAM »  Height: 5 ft. 8 in. »  Weight: 200 lbs. »  Body mass index (BMI): 30 »  Waist circumference: 42 in. »  Pulse: 84 »  Blood pressure: 140/86 mm Hg »  Diminished pedal pulses »  Absent Achilles reflexes »  Remainder of examination is normal LABORATORY VALUES »  Fasting blood glucose: 118 mg/dL »  Uric acid: 9 mg/100 mL »  Remainder of chemistry panel is normal »  Lipid profile   --  Total cholesterol: 190 mg/dL   --  Triglycerides; 190 mg/dL   --  HDL: 19 mg/dL   --  Calculated LDL cholesterol: 133 mg/dL   --  hs CRP: 2.0 mg/dL (normal, <0.8)   --  Microalbumin/creatinine ratio: 40 µg/mg creatinine (normal, <30) NAVIGATION »  Q1: What findings are of concern to you at this visit? »  Q2: What other findings are suggestive of the Insulin Resistance Syndrome? »  Q3: How would you categorize SW’s blood pressure? »  Q4: What are the benefits of treating hypertension? »  Q5: What is the recommended initial therapy for patients with hypertension? »  Q6: What other management strategies would you institute at this time? »  Q7: How do you explain SW’s worsening lipid profile and fasting glucose levels? »  Q8: What is your diagnosis now? »  Q9: What are your treatment goals for SW? »  Q10: How should you modify SW’s antihypertensive regimen at this time?	Course of Treatment SW’s Primary Care physician (PCP) starts him on hydrochlorthiazide 25 mg daily. In 2 weeks, his blood pressure has decreased to 140/86 mm Hg. His physician adds aspirin (81 mg) daily. Q: What is the recommended initial therapy for patients with hypertension? A: The JNC-7 guidelines3 recommend that thiazide- type diuretics be used as initial therapy for most patients with hypertension, either alone or in combination with one of the other classes with demonstrated benefit. In clinical studies, including the recently published Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT),4 diuretics have been virtually unsurpassed in preventing cardiovascular complications of hypertension. Diuretics also have the advantage of being more affordable than other antihypertensive agents.
	Questions? Contact 1-888-JEFF-CME (533-3263) or http://jeffline.jefferson.edu/jeffcme
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