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Introduction
1. CASE
A 56 year old man comes in for a routine health maintenance visit. He is new
to your practice and has no specific complains today. He has hypertension for which
he takes hydrochlorothiazide, and he occasionally takes an aspirin because someone
told him that it was good for his. He has no other significant medical story. He does
not smoke cirgarettes, occasionally drinks alcohol, and does not excrise. His father
died of a heart attack at age 60 years and his mother died at age 72 years of cancer.
He has two younger sisters who are in good health. On examination, his blood
pressure is 130/80 mmHg and his pulse is 75 bpm. He is 6 ft tall and weights 200 lb.
His complete physical examination is normal. You order a fasting lipid panel, which
subsequently retruns with the following results : total cholesterol 242 mg/dl;
triglycerides 138 mg/dl; hight-density lipoprotein (HDL) cholesterol 48 mg/dl; adn
low-density lipoprotein (LDL) cholesterol 155 mg/dl.
2. KEYWORD
a) A 56 year old man
b) Has hypertension for which he takes hydrochlorothiazide and
c)
d)
e)
f)
g)
h)
i)
j)
k)
3. TAKING NOTES
Surname
Firts name
Age
Sex
Marital Status
Occupation
Present Complaint
General Condition
ENT
RS
CVS Pulse
BP
GIS
GUS
CNS
Immadiate History
Point Of Note
Investigations
Diagnosis
II. DISCUSSION
1. Definition
No Name
56 years old
Male
No specific complaints, routine health
maintenance visit.
Normal
75 bpm
130/80 mmHg
He has hypertension
He
takes
hydrochlorothiazide
and
occasionally takes an aspirin
Total cholesterol 242 mg/dL, triglycerides
138 mg/dL, HDL 48mg/dL, LDL 155mg/dL
Hypertension
3. Risk Factor
a) Hectic and stress filled life style
b) Unhealthy food habits
c) Obesity
d) Excessive consumption of liquors
e) Smoking
f) Over consumption of tea/coffee
g) Insufficient rest and sleep
h) Metabolic disorders
i) Hardening of the arteries
j) Excessive use of pain killers and other strong medicines
k) Genetic disorders
l) Over consumption of oily food and fast food
m) High salt intake
n) Emotional and Physical stress
o) Family history of hypertension
4. Clinical Manfiestasion
High blood pressure (HBP) it self usually has no signs or symptoms.
Rarely, headaches may occur. You can have HBP for years without knowing it.
During this time, the condition can damage your heart, blood vessels, kidneys,
and other parts of your body.
Some people only learn that they have HBP after the damage has caused
problems, such as coronary heart disease, stroke, or kidney failure.
And this clinical manifestasi usually the patient feels :
a)
b)
c)
d)
e)
f)
g)
gFuatioencrsf
oVnisprblem
Chestpain
Dyifcultnbreahg
gIruelahtb
oBndlthieur
Ponudgiyrchkest,a
Like symptoms, physical findings depend on the cause of hypertension,
its duration and severity, and the degree of effect on target organs.
a) Blood pressure - On initial examination, pressure is taken in both arms
and, if lower extremity pulses are diminished or delayed, in the legs to
exclude coarctation of the aorta. An orthostatic drop is present in
pheochromocytoma. Older patients may have falsely elevated readings by
sphygmomanometry because of noncompressible vessels. This may be
suspected in the presence of Osler's sign - a palpable brachial or radial
artery when the cuff is inflated above systolic pressure. Occasionally, it
may be necessary to make direct measurements of intra-arterial pressure,
especially in patients with apparent severe hypertension who do not
tolerate therapy.
b) Retinas - Narrowing of arterial diameter to less than 50% of venous
diameter, copper or silver wire appearance, exudates, hemorrhages, or
papilledema are associated with a worse prognosis.
c) Heart and arteries Left ventricular enlargement with a left ventricular
heave indicates severe or long-standing hypertrophy. Older patients
frequently have systolic ejection murmurs resulting from calcific aortic
5. Clasification Of Hipertension
There are two major types of hypertension and four less frequently found
types.
1. Primary or essential hypertension, that has no known cause, is diagnosed
in the majority of people.
2. Secondary hypertension is often caused by reversible factors, and is
sometimes curable.
The other types include:
a) Malignant Hypertension
This the most severe form of hypertension, is severe and
progressive. It rapidly leads to organ damage. Unless properly treated, it is
fatal within five years for the majority of patients. Death usually comes from
heart failure, kidney damage or brain haemorrhage. However, aggressive
treatment can reverse the condition, and prevent its complications. Malignant
6. Diagnosis
A. History
Ask about previous cardiovascular events because they often suggest an
increased probability of future events that can influence the choice of drugs for
treating hypertension and will also require more aggressive treatment of all
cardiovascular risk factors. Also ask patients if they have previously been told that
they have hypertension and, if relevant, their responses to any drugs they might have
been given.
Ask about Important previous events include : stroke or transient ischemic
attacks or dementia, coronary artery disease, including myocardial infarctions, angina
pectoris, and coronary revascularizations, Heart failure or symptoms suggesting left
ventricular dysfunction (shortness of breath, edema), Chronic kidney disease,
peripheral artery disease, diabetes and sleep apnea.
Ask about other risk factors. Thus, knowing about age, dyslipidemia,
microalbuminuria, gout, or family history of hypertension and diabetes can be
valuable. Cigarette smoking is a risk factor that must be identified so that counseling
can be given about stopping this dangerous habit.
Ask about concurrent drugs.
B. Physical Examination
1) Measuring blood pressure.
2) Document the patients weight and height and calculate body mass index.
3) Waist circumference.Why is this important?Independent of weight, this helps
determine whether a patient has the metabolic syndrome or is at risk for type 2
Criteria
BP 140/90 mmHg or Higher at initial
visit and at two follow-up visits within 1
month of the initial visit.
7. Treatment
For hypertension, the treatment goal for systolic blood pressure is usually
<140 mm Hg and for diastolic blood pressure <90 mm Hg. . It is important to inform
patients that the treatment of hypertension is usually expected to be a life-long
commitment and that it can be dangerous for them to terminate their treatment with
drugs or lifestyle changes without first consulting their practitioner.
B. Pharmacologic treatment
1) Angiotensin converting enzyme inhibitor
These agents reduce blood pressure by blocking the reninangiotensin system. They do this by preventing conversion of
angiotensin I to the blood pressureraising hormone angiotensin
II. They also increase availability of the vasodilator bradykinin
by blocking its breakdown.
Do not combine angiotensin receptor blockers with angiotensin
receptor blockers. Angiotensin-converting enzyme inhibitors
must not be used in pregnancy, especially in the second or third
trimesters, since they can compromise the normal development
of the fetus.
2) Angiotensin Receptor Blockers
Like angiotensin-converting enzyme inhibitors, antagonize the
reninangiotensin system. They reduce blood pressure by
blocking the action of angiotensin II on its AT1 receptor and thus
prevent the vasoconstrictor effects of this receptor.
When combined with either calcium channel blockers or
diuretics, they become equally effective in all patient groups. Do
not combine angiotensin receptor blockers with angiotensinconverting enzyme inhibitors.
Angiotensin receptor blockers must not be used in pregnancy,
especially in the second or third trimesters.
3) Thiazide and Thiazide-like Diuretics
8. Education
If you have high blood pressure, there are steps you can take to get it under
control, including:
a) Ask your doctor what your blood pressure should be: set a goal to lower your
pressure with your doctor then discuss how you can reach your goal. Work
with your health care team to make sure you meet that goal.
b) Take your blood pressure medication as directed: if you are having trouble,
ask your doctor what you can do to make it easier. For example, you may
want to discuss you medication schedule with you doctor if you are taking
multiple drugs at different times of the day. Or you may want to discuss side
effect you are feeling, or the cost of you medicine.
c) Quit smoking-and if you dont smoke, dont start: You can find tips and
resources at CDCs smoking and tobacco web site or Be Tobacco Free web
site.
d) Reduce sodium: Most American consume too much sodium, and it raises
blood pressure in most people.
The are other healthy habits, that can help keep your blood pressure under
control:
a) Achieve and maintain a healthy body weight.
b) Participate in 30 minutes of moderate physical activity on most days of the
week.
c) Eat a healthy diet that is high in fruits and vegetables and low in sodium,
saturated fats, trans fat, and cholesterol.
d) Manage stress
e) Limit the amount of alcohol you drink (no more than one drink each day for
women and two for men).
f) If you have high blood pressure and are prescribed medication, take it as
directed.
g) If you have a family member who has high blood pressure, you can help by
taking many of the steps listed above with them. Go for walks together or
cook meals with lower sodium.
h) Check your blood pressure regularly.
9.Complication
The excessive pressure on your artery walls caused by high blood pressure
can damage your blood vessels, as well as organs in your body. The higher you blood
pressure and the longer it goes uncontrolled, the greater the damage.
Uncontrolled high blood pressure can lead to :
a) Heart attack or stroke: high blood pressure can cause hardening and
thickening of the arteries (artherosclerosis), which can lead to a heart
attack, stroke or other complication.
b) Aneurysm: Increased blood pressure can cause your blood vessels to
weaken and bulge, forming an aneurysm. If an aneurysm ruptures, it can
be life-threatening.
c) Heart failure: To pump blood pressure can cause your blood vessels, your
heart muscle thickens. Eventually, the chickened muscle may have a hard
time pumping enough blood to meet you bodys needs, which can lead to
heart failure.
d) Weakened and narrowed blood vessels in your kidney: This can prevent
these organs from functioning normally.
e) Thickened, narrowed or torn blood vessels in the eyes: This can result in
vision loss.
10. Prognosis
The prognosis for hypertension depends on:
a) How long youve got it
b) How severe it is
c) If you have other conditions (such as diabetes) that increase the
risk of complication.
Hypertension can lead to a poor prognosis even if you do not have symptoms.
When high blood pressure is treated adequately, the prognosis is much better. Both
lifestyle changes and medicines can control your blood pressure
III. CONCLUSION
REFERENCE