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Hypertension case study # 3 Mr Brown a 62-year-old African American man with “very labile blood pressure” (BP) for at least 11 years presents to his primary care provider’s office with the chief complaint of having “flunked” an insurance physical. Immediately after retirement (last month), he applied for a supplemental life insurance policy but last week he learned that his application was refused. He feels well and has no complaints. He says that his BPs have run “high” in the last 10 to 15 years, but always settle down when he rests for 10 minutes. He suspects that part of the reason for his denial of insurance was his BP, which was measured in his office by the physician assistant who performed his insurance physical as 148/98 mm Hg. He remembers that this measurement came in the middle of a very busy day, with 3 conference calls and a very stressful “exit interview” for one of his subordinates. He has been taking his BPs at home for the last week, and brings a printout of the last 15 readings; the average is 151.2/90.4 mm Hg, but the range is 130/72 to 160/102 mm Hg. He says he has not visited a physician for the last 10 years or so, because he’s been so busy with his work and his family. He brings copies of documents describing the results of the insurance physical that he had 2 weeks ago: abnormalities included a seated BP of 155/95 mm Hg, a glucose (allegedly fasting) of 156 mg/dL, a serum creatinine of 1.5 mg/dL, a (random) urinary albumin/creatinine ratio of 954 mcg/g, and an A1c of 7.8%. He was, of course, told to “discuss these results with his physician.” He recalls being denied a supplemental disability insurance policy about 6 years ago, allegedly based on “protein in my urine,” but didn’t follow up this abnormality. He denies previous treatment for hypertension or diabetes. He denies prior episodes of hypokalemia, muscle cramps, palpitations, headache, sweating attacks, visual disturbances, polyuria, polydipsia, and fevers. Medical History: “Labile blood pressures” for at least 11 years (as above) Medications: One multivitamin tablet po daily Allergies: No known drug allergies. He had no problems with the combination of trimethoprim + sulfamethoxazole (taken as prophylaxis for traveler’s diarrhea for a trip to Mexico) when he was 50 years old. Tobacco History: Negative (ie, never used tobacco products of any kind) Alcohol History: Typically has 5 to 6 alcoholic beverages/week, usually beer or wine, more commonly on the weekend, or when entertaining customers in restaurants. Drug Abuse History: Denied; said to have had negative random drug screens at work. Family History: Father, aged 88, hypertension since age 62, survived a myocardial infarction (MI) at 72 Mother, aged 87, hypertension since age 68, osteopenia, “early diabetes” controlled with dietary measures Brother, aged 61, no known medical problems, but “doesn’t visit doctors much” Sister, aged 63, breast cancer at age 59, had lumpectomy and adjuvant radiation and chemotherapy, with no evidence of disease at last follow-up A maternal uncle died nearly 12 years ago, at age 70, after “3 miserable years” on dialysis, said to be due to longstanding diabetes that he didn’t attempt to control Social History: Happily married for the second time for the last 17 years; lives with wife and 2 teenagers in single-family dwelling in nearby suburb Retired 4 weeks ago as vice president for finance of a local Fortune 500 company He felt that the “stress” of his job (especially during the recent financial downturn in the US economy) was “ruining his family life,” and therefore accepted “early retirement” when it was offered Volunteers 16 hours/week at the local Executive Service Corps, providing advice to nonprofit organizations and out-of-work individuals Coaches 15-year-old son’s baseball and 16-year-old daughter’s soccer teams on weekends Plans on starting 18 holes of golf twice weekly, “as soon as I have time” Review of Systems: Constitutional: No recent poor health, changes in weight, fatigue or headaches. Eyes: No eye disease or injury, no blurred or double vision, and no symptoms of glaucoma. ENT: No hearing loss, tinnitus, earaches or otorrhea, rhinitis or sinusitis, epistaxis, oral ulcerations, bleeding gums, bad breath, or sore throat. Cardiovascular: No history of heart trouble, chest discomfort or other symptoms consistent with angina pectoris, palpitations, orthopnea, dyspnea, or pedal edema. Respiratory: No chronic or frequent cough, hemoptysis, dyspnea, or wheezing. Gastrointestinal: No loss of appetite, change in bowel habit, nausea, vomiting, diarrhea, constipation, hematochezia or hematemesis, or heartburn. Has gained about 20 pounds and 2 inches in the waistline in the last 10 years, and about double that since his wedding 17 years ago. GU: No diminution in urinary volume or frequency, polydipsia, dysuria, hematuria, incontinence, nocturia, kidney stones. Musculoskeletal: No joint pain, stiffness or swelling, weakness of muscles or joints, muscle pain or cramps, back pain, or cold extremities. Skin: No rash, pruritus, change in color of skin, hair or nails, varicose veins, breast pain lumps or discharge, sun exposure, or skin lesions. Neurological: No major headaches, lightheadedness, dizziness, seizures, dysesthesias, tremors, or head injury. Psychiatric: No memory loss or confusion, nervousness, depression, or insomnia. Endocrine: No “hormonal” problems, thyroid illness, polydipsia, polyuria, heat or cold intolerance, or xerodermia. Hematologic: No problems recovering after cuts or bruises, anemia, phlebitis, or swollen lymph nodes. Physical Examination: Well-developed, well-nourished man in no acute distress. Height: 66 inches, weight: 224 pounds, BMI = 36.2 kg/m2, waist circumference = 42 in. Supine BP readings: o Right: 150/94 mm Hg, pulse is 76 beats/minute, and regular o Left: 148/92 mm Hg, pulse is 72 beats/minute, and regular Seated BP readings: o Right: 150/92 mm Hg, pulse is 76 beats/minute, and regular o Left: 148/94 mm Hg, pulse is 80 beats/minute, and regular Standing BP readings: o Right: 156/98 mm Hg, pulse is 84 beats/minute, and regular o Repeated after 2 minutes: 150/90 mm Hg, with a pulse of 76 beats/minute and regular HEENT: The sclerae are white, and the conjunctivae clear. PERRL. Fundi show Grade I hypertensive retinopathy on the Keith-Wagener-Barker scale. The ears harbor no scars, lesions, or masses; he has bilateral earlobe creases. Hearing is grossly intact bilaterally. The pharynx is unremarkable. Neck: Supple, without thyromegaly, lymphadenopathy, or jugular venous distension. Lungs: Clear to auscultation and percussion bilaterally. Cardiovascular: Regular rate and rhythm, without extra sounds, murmurs, or rubs. There is no cyanosis, clubbing, or edema. All pulses are 2+ and equal. Abdomen: Nontender, without organomegaly, or bruits. Rectal examination is unremarkable. Neurological: All cranial nerves are intact. Upper and lower extremities have 5/5 strength. Reflexes: 2+ and equal. Mental status is normal. Laboratory results Total cholesterol High-density lipoprotein cholesterol Low-density lipoprotein cholesterol Triglycerides Serum glucose (fasting) Serum potassium Serum BUN Serum Creatinine eGFR Albumin/creatinine ratio (firstvoided AM specimen) Uric acid Urinalysis EKG 150 mg/dL 50 mg/dL 78 mg/dL 110 mg/dL 132 mg/dL 3.9 mEq/L 29 mg/dL 1.5 mg/dL 50 mL/min/1.73 m2 987 mg/g 8.2 mg/dL Normal except 2+ protein, 1+ glucose, negative microscopic exam Normal 1. Define hypertension for adults and children. (10 points) Hypertension is the force at which the heart pumps to perfuse the organs and tissues. It depends greatly on volume, flow and amount of constriction. Hypertension should be diagnosed after 1-2 readings within 1-2 months shows pressures greater than 120/80 in adults and in children it depends on age, sex and height. They must be in the 95th percentile or higher to be diagnosed. 2. Identify target BP goals in treatment for you patient above what would your target BP be? (10 points) Mr. Brown should have a target blood pressure of less than 130/80 given his family history and current state of labs. Normally, less than 140/90 is used for primary prevention of CAD. JNC recommends an ideal blood pressure of 120/80, getting it as close as possible to this value is best for prevention of complications. 3. Describe the evaluation for an initial clinical visit for hypertension. (10 points) An initial clinic visit for hypertension includes a thorough interview for past medical history, surgeries, allergies and current state of health. In addition, family history is very important to know. Physical exam, and labs works need to be done. Labs include: CBC, ESR, UA and culture, CMP, lipids, TSH, uric acid and calcium. In addition, an EKG should be obtained. Lastly, a general evaluation of the patient’s diet (caffeine, salt), exercise, alcohol, smoking, and stress levels should be evaluated. Secondary causes should be ruled out by examining history, exam and lab work. 4. Identify common secondary causes for hypertension, and include the appropriate diagnostics to rule in/out (diagnostics include significant positives/negatives on exam, labs, other testing) (10 points) Secondary causes include: Renal artery stenosis: would suspect in those under 30, greater than 50, with a history of atherosclerosis, a family history of RAS, or abdominal bruits. UA and creat would be indicative, would need a renal arteriogram to make sure. Pheochromocytoma: suspect in HTN, headaches, hyperhydrosis, hypermetabolic state, and hyperglycemia. Also in hypertension after TCAs, family history, hypertension with abdominal palpation, labile hypertension. Get a urine VMA and CT scan to diagnose. Hyperaldosteronism: suspect in those with weakness, fatigue, headaches, hypertension and hypokalemia. Diagnostic with unprovoked hypokalemia, aldosterone challenge, and CT scan. Coarctation of the aorta: Suspect in younger, possible claudication, fatigue, late systolic murmur, apical heave. Would be seen on x-ray. Further testing warrants CT scan and echo. Cushing’s syndrome: suspect in weight change, fatigue, temperature intolerance, edema, changes in bowel habits. Indicated on TSH levels, weakness, and muscle spasms. Warrants further thyroid testing. Sleep apnea: reports of daytime fatigue, family reports snoring, apneic breathing. Needs sleep study. Thyroid disease: Suspect in edema, buffalo hump, truncal obesity, hirsuitism. Lab abnormalities would warrant a free cortisol level, check 24hr urine. Alcohol: based on history. Would maybe see some lab abnormalities, low albumin. Patient may not be forthcoming of actual intake. Medications (OC, NSAID): eliminate these meds to see if changes blood pressure, use alternate forms. 5. Identify life-style changes for management of hypertension, Be specific. What are the expected values from each? (10 points) Weight reduction: maintain a healthy weight, or losing 10kg results in a 5-20 decrease. DASH diet: loss of 8-14 Low/no added sodium: loss of 2-8 Regular exercise: loss of 4-9 Limited alcohol: loss of 2-4 All losses refer to SBP. In addition, quitting smoking decreases the risk of a cardiovascular event. 6. For your patient above what is your diagnosis(es) (10 points) Hypertension: currently uncontrolled Diabetes, Type 2: uncontrolled Renal insufficiency: moderate Proteinuria Hyperuricemia Obesity 7. You decide to initiate treatment. Indicate your treatment plan and rationale for each treatment plan. For pharmacological intervention state class, mechanism of action and possible side effects of each drug). (20 points) Mr. Brown needs the following medications: ACE inhibitor (protective to kidneys in those with diabetes) Lisinopril 10mg po qd. Works by blocking conversion of angiotension, which results in decreased bp, and less aldosterone production. Side effects could be angioedema, cough, GI upset, and headache. Antidiabetic agent Metformin 1000mg po BID. Works by increasing peripheral use of glucose, increases insulin production, decreases hepatic glucose production. Side effects typically are GI related. He needs his liver and kidney monitored while on this medication. I would also recommend changing his MVI to a prenatal vitamin (less harsh on the kidneys). He also needs to see a nephrologist, and ophtamologist It is highly important he follow a low fat, low salt diet. He also needs to cut down/stop his alcohol intake. Given his current retirement state, hopefully some stress relief will aid in his lifestyle changes. He also should be exercising 30 min a day. 8. Briefly discuss how pediatric hypertension differs from adult hypertension in terms of common causes (both primary and secondary), assessment, treatment and prevention? (20 points) Generally, children generally have secondary hypertension more often as compared to adults. Children’s hypertension is generally related to endocrine disorders, coarctation of the aorta and renal disease. Also, primary hypertension in children is more prevalent than secondary, with no known cause. Weight and family history are most commonly identified in those children with hypertension. Assessment of hypertension proves difficult in children, as there are standardized charts with percentiles. Children are considered hypertensive with three consecutive blood pressure reading in the 95th percentile or greater in comparison with their height, weight and sex. There is not a standard reading to measure against, as there is with adults (120/80). Treatment in adults is outlined by JNC 7. Initial treatment is lifestyle changes, followed by a diuretic, unless other compounding factors are present. Children need a thorough e valuation to rule out other causes, and then lifestyle changes need to be made. After that, the NHBPEP has set guidelines that recommend to only treat if the child has symptoms related to the blood pressure, evidence of organ damage, diabetes, or other cardiovascular risks. In these cases, they recommend starting with a beta blocker. Use of a calcium channel blocker or ACE is also recommended, however, the use of a diuretic is not. These may cause damage in developing children, and need close monitoring. Finally, prevention is similar in both adults and children. Lifestyle changes are central to prevention. Low fat diet, exercise and salt reduction is central to prevention. In addition, limiting alcohol and avoidance of smoking also helps in prevention of high blood pressure. The same suggestions are given to adults and children, diet and exercise leads to healthier outcomes. If adults set good examples to their children, the kids are less likely to develop bad habits and an unhealthy lifestyle.