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Adopted from UNSOM CPS Case CPSI-010 Edgar Campbell
Contributing Faculty:
Michael Bloch, MD
Violeta Mutafova-Yambolieva, MD, PhD
Presenting Faculty: Michael J Bloch, MD
PART 1 (Presented after Introduction Monday at 8am)
CC:
The patient is a 65 year-old Caucasian male referred to the Internal Medicine
Clinic with a chief complaint of “my blood pressure is too high.”
HPI:
Mr. Campbell has had a diagnosis of hypertension for 20 years and has been
on medication for about 12 years. He is currently taking HCTZ 25 mg daily
and Atenolol 100 mg daily. He states that while he has had some elevated
readings his doctors usually tell him that his BP is “OK.” Three weeks ago he
was seen in Urgent Care because of a cold and his BP was found to be
190/110. Lisinopril 40 mg daily was added. Ten days later he was seen again
and his BP was still elevated so amlodipine 5 mg daily was added. He has no
headaches, chest pain, or complaints of confusion. He describes good
adherence with his medications. He does not measure his BP at home. He
denies any known use of stimulants anti-inflammatories or illicit drugs.
PMH: Carotid atherosclerosis with left carotid endarterectomy 4 years ago
Coronary artery disease with percutaneous coronary intervention 2 years
ago
Hypertension
Dyslipidemia
Gastro-esophageal reflux (GERD)
Medications:
Nitroglycerine SQ PRN for chest pain.
Hydrochlorthiazide (HCTZ) 25 mg PO daily
Lisinopril 40 mg. PO daily
Amlodipine 5 mg PO daily
Aspirin 81mg PO daily
Clopidogrel 75 mg daily
Lovastatin 20 mg PO daily
Family History:
Father died in automobile accident when patient was a child
Mother had hypertension and died at age 67 of a stroke.
Social History:
Was factory worker – now disabled.
Stopped smoking 4 years ago following diagnosis of CAD. Smoked 1-2 packs a
day for 40 years prior to that.
Alcohol -one or two beers a week.
Wife died 6 years ago, lives alone, has no children. Spends most of his time
watching television or playing cards with friends.
Review of Symptoms:
General: Denies fever, chills and weight loss, or difficulty sleeping.
HEENT: Denies headache, vision changes, hearing changes.
Respiratory: No cough or shortness of breath
Cardio: No chest pain or palpitations; no claudication; +occasional ankle
swelling
GI: Denies nausea, vomiting, constipation, or diarrhea
GU: Denies hematuria, polyuria or other issues
Musculoskeletal: No joint pain or myalgias
Neurological: no focal weakness, change in mentation, strength or sensation
Mood: No depression or anxiety
Physical Exam:
Vitals:
Weight : 205 lbs.
Height : 5’9”
BP : 225/122
Pulse 80 regular
RR : 14
BMI 30.3
Waist Circumference 42”
General: Somewhat obese white male in no acute distress
Head: Normocephalic and atraumatic; Fundoscopic exam – moderate AV nicking.
Neck: No cervical bruits.
Well healed left neck incision
Chest: normal respiratory expansion
Lungs: Clear without wheezes or rales
Cardiovascular: Jugular venous pressure normal. Regular rate; normal S1 and S2
and no murmurs. PMI laterally displaced. Lower extremity pulses full
Abdomen: No masses or organomegaly. Loud bruit audible in left flank.
Extremities: No edema, pulses full.
Skin – no xanthomas or rash
Neuro : clear mentation; no pronator drift; Cranial nerves intact; gait normal;
Affect :normal.
LAB
BUN
Creatinine
eGFR
Total Cholesterol
HDL-C
LDL-C
Triglycerides
Sodium
Potassium
Glucose
Urinalysis
Chest XRAY
18 mg/dL
1.4 mg/dL
52 ml/min/1.72m2
244 mg/dL
35 mg/dL
118 mg/dL
225mg/dl
141 meq/L
3.3 meq/L
112mg/dl
(8-20)
(0.7-1.3)
(>60)
(150-199)
(>40)
(<130)
(<150)
(135-147)
(3.5-5.2)
(<100)
No protein; otherwise unremarkable
Normal
EKG LVH without other abnormalities
The Patient is admitted to the hospital for BP control and evaluation.
Questions Part 1: (Please respond on Webcampus by 7pm on Monday)
1. What is the clinical definition of hypertension? Prehypertension? What stage of
hypertension does this patient exhibit (see JNC7)?
2. Define hypertension urgency and hypertensive emergency. Does this patient
meet criteria for either diagnosis?
3. What percentage of patients with hypertension are not fully adherent with their
blood pressure medications? Why do you think that is?
4. The coronary arteries fill during what part of the cardiac cycle? What is the
potential downside of overtreatment of blood pressure in a patient with established
coronary artery disease?
5. After I stood on my head and returned to a standing position I was sweating –
why was that?
PART 2 (Released Monday at 7pm)
The patient was evaluated and treated as an outpatient. Doxazosin 2 mg each night
was added to his regimen.
Additional diagnostic tests were ordered per below.
Additional lab:
Plasma renin activity (PRA)
Serum aldosterone
9.8
21.3
(high)
(high)
Questions 2: (Please respond on Webcampus by Tuesday at 7pm)
1. What is the prevalence of hypertension in the US adult population? What is the
prevalence in this patient’s age group? What is the difference between the terms
‘prevalence’ and ‘incidence’;
2. What is the relative risk of stroke in the hypertensive vs non-hypertensive
population? What does the term ‘relative risk’ mean? What does the term
‘population attributable risk’ mean?
3. What is the difference between primary and secondary hypertension? What are
common forms of secondary hypertension?
4. Are the PRA and aldosterone levels consistent with a diagnosis of primary
aldosteronism?
5. Given this additional blood work, what do you think is the significance of the
abdominal bruit on physical exam?
PART 3 (Released on Webcampus Tue At 7pm)
A renal artery duplex ultrasound demonstrates 90% stenosis of the left main
renal artery at its origin with minimal disease on the right.
Renal angiography with stent placement is performed with fall in BP over the
next few weeks to
146/80.
PRE-STENT
POST-STENT
Questions Part 3: (Do Not Need to be answered on webcampus, but each student
should be prepared to discuss intelligently when called up on in class at wrap up)
1. What are the two main pathophysiologic causes of renal artery stenosis
and at what ages are they each usually seen (hint: one type is in younger
patients and one type in older patients)?
2. How do ACE inhibitors, angiotensin receptor blockers, and beta blockers
lower blood pressure in cases of renal artery stenosis? Are they safe to
use in this setting?
3. Why don’t we screen all hypertensives for renal artery stenosis? What do
the terms positive and negative predictive value mean and why are they
relevant to this discussion?
4. I have a hypothesis that putting a stent in the renal artery in patients with
renovascular hypertension will improve blood pressure. How would I
test this hypothesis?
5. In general, why do our blood pressure medications work better in
combination than as monotherapy?