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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?