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case hipertensi

case hipertensi

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Published by: Bulqis Vellaya on Jun 06, 2013
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Case Report Hypertension

By: Bulqis Vellaya Arlem NIM: 0808113101

Supervisor : dr.Rayendra, Sp.PD, FINASIM
20 Maret 2013

• A systolic blood pressure ( SBP) >139 mmHg and/or • A diastolic (DBP) >89 mmHg. • Based on the average of two or more properly measured, seated BP readings. • On each of two or more office visits.

Accurate Blood Pressure Measurement
• The equipment should be regularly inspected and validated. • The operator should be trained and regularly retrained. • The patient must be properly prepared and positioned and seated quietly for at least 5 minutes in a chair. • The auscultatory method should be used. • Caffeine, exercise, and smoking should be avoided for at least 30 minutes before BP measurement. • An appropriately sized cuff should be used.

BP Measurement
• At least two measurements should be made and the average recorded. • Clinicians should provide to patients their specific BP numbers and the BP goal of their treatment.

Factors Influencing the Development of Hypertension

Patophysiology .

nih.g ov .nhlbi.Classification www.

who also have diabetes or kidney disease. .Pre-HTN • Individuals who are prehypertensive are not candidates for drug therapy but • Should be firmly and unambiguously advised to practice lifestyle modification • Those with pre-HTN. drug therapy is indicated if a trial of lifestyle modification fails to reduce their BP to 130/80 mmHg or less.

(Malignant Hypertension) .Hypertensive Crises • Hypertensive Urgencies: No progressive target-organ dysfunction. (Accelerated Hypertension) • Hypertensive Emergencies: Progressive end-organ dysfunction.

• Usually due to under-controlled HTN. shortness of breath or chest pain. . • Examples: Highly elevated BP without severe headache. • Without progressive end-organ dysfunction.Hypertensive Urgencies • Severe elevated BP in the upper range of stage II hypertension.

• Require emergent lowering of BP. • With progressive target organ dysfunction.Hypertensive Emergencies • Severely elevated BP (>180/120mmHg). • Examples: Severely elevated BP with: Hypertensive encephalopathy Acute left ventricular failure with pulmonary edema Acute MI or unstable angina pectoris Dissecting aortic aneurysm .

• Secondary HTN: less common cause of HTN ( 5%).Types of Hypertension • Primary HTN: also known as essential HTN. accounts for 95% cases of HTN. . secondary to other potentially rectifiable causes. no universally established cause known.

Causes of Secondary HTN • Common – Intrinsic renal disease – Renovascular disease – Mineralocorticoid excess – Sleep Breathing disorder • Uncommon – – – – Pheochromocytoma Glucocorticoid excess Coarctation of Aorta Hyper/hypothyroidism .

Patient Evaluation Objectives • (1) To assess lifestyle and identify other cardiovascular risk factors or concomitant disorders that may affect prognosis and guide treatment • (2) To reveal identifiable causes of high BP • (3) To assess the presence or absence of target organ damage and CVD .

65 for women) Family history of premature cardiovascular disease (men under age 55 or women under age 65) .(1) Cardiovascular Risk factors • • • • • • • • • Hypertension Cigarette smoking Obesity (body mass index ≥30 kg/m2) Physical inactivity Dyslipidemia Diabetes mellitus Microalbuminuria or estimated GFR <60 mL/min Age (older than 55 for men.

(2) Identifiable Causes of HTN • • • • • • Sleep apnea Drug-induced or related causes Chronic kidney disease Primary aldosteronism Renovascular disease Chronic steroid therapy and Cushing’s syndrome • Pheochromocytoma • Coarctation of the aorta • Thyroid or parathyroid disease .

(3) Target Organ Damage • Heart Left ventricular hypertrophy Angina or prior myocardial infarction Prior coronary revascularization Heart failure • Brain Stroke or transient ischemic attack • Chronic kidney disease • Peripheral arterial disease • Retinopathy .

Untreated Heart Attack Enlarged hypertension can result in: --Kidney damage --Stroke --Blindness Arteriosclerosis heart .

COPD: Preclude the use of b-blockers • Heart failure: ACE inhibitors indication • DM: ACE preferred • Polyuria and nocturia: Suggest renal impairment .History • Angina/MI Stroke: Complications of HTN. Angina may improve with b-blokers • Asthma.

History-contd. • Claudication: May be aggravated by b-blockers. atheromatous RAS may be present • Gout: May be aggravated by diuretics • Use of NSAIDs: May cause or aggravate HTN • Family history of HTN: Important risk factor • Family history of premature death: May have been due to HTN .

• Family history of DM : Patient may also be Diabetic • Cigarette smoker: Aggravate HTN.History-contd. independently a risk factor for CAD and stroke • High alcohol: A cause of HTN • High salt intake: Advice low salt intake .

.Examination • Appropriate measurement of BP in both arms • Optic fundi • Calculation of BMI ( waist circumference also may be useful) • Auscultation for carotid. abdominal. and femoral bruits • Palpation of the thyroid gland.

masses.Examination-contd. and abnormal aortic pulsation • Lower extremities for edema and pulses • Neurological assessment . • Thorough examination of the heart and lungs • Abdomen for enlarged kidneys.

• HDL cholesterol. LDL cholesterol.Routine Labs • EKG. and triglycerides. • Optional tests urinary albumin excretion. albumin/creatinine ratio. • Urinalysis. . and calcium. serum potassium. • Blood glucose and hematocrit. creatinine ( or estimated GFR).

Goals of Treatment • Treating SBP and DBP to targets that are <140/90 mmHg • Patients with diabetes or renal disease. the BP goal is <130/80 mmHg • The primary focus should be on attaining the SBP goal. • To reduce cardiovascular and renal morbidity and mortality .

Benefits of Treatment • Reductions in stroke incidence. . averaging >50 percent. averaging 20–25 percent • Reductions in HF. averaging 35–40 percent • Reductions in MI.

nih.Lifestyle modifications www.gov .nhlbi.

DASH Diet • Dietary approaches to Stop Hypertension • As effective as one medication .

Pharmacology 1. ACE inhibitor. Adrenergic Blocker (alfa blocker. diazoxide dll) Single or Combination . beta blocker. 3. 4. Diuretic ( Thiazid ) 2. Vasodilator ( nitrogliserin. Calsium Antagonist 5. alfa-beta blocker).

[new 2011] . Offer antihypertensive drug treatment to people aged under 80 years with stage 1 hypertension who have one or more of the following: • target organ damage • established cardiovascular disease • renal disease • diabetes • a 10-year cardiovascular risk equivalent to 20% or greater.Initiating treatment 1.

This is because 10year cardiovascular risk assessments can underestimate the lifetime risk of cardiovascular events in these people.2. 3. consider seeking specialist evaluation of secondary causes of hypertension and a more detailed assessment of potential target organ damage. Offer antihypertensive drug treatment to people of any age with stage 2 hypertension. cardiovascular disease. For people aged under 40 years with stage 1 hypertension and no evidence of target organ damage. . renal disease or diabetes.


K A S U S .

Keluhan Utama Nyeri kepala sejak 1 minggu sebelum masuk rumah sakit (SMRS) .

Riwayat Penyakit Sekarang 3 tahun SMRS • sering sakit kepala. saat diperiksa TD190/100 mmHg.muntah (-) Lalu pasien berobat ke Puskesmas. lalu pasien tidak kontrol teratur. . kepala terasa berat. sakit juga dirasakan pada bagian tengkuk. sehingga pasien sulit berjalan karena nyeri. mual (-). 1 tahun SMRS • lututnya sering terasa sakit. pasien didiagnosis hipertensi. Untuk menghilangkan nyerinya pasien rutin minum jamu sekali dua hari setiap pagi sejak 6 bulan terakhir.

darah segar (-). Nyeri ulu hati (+). Nyeri terasa berdenyut-denyut diseluruh bagian kepala. Ada rasa mual sampai muntah berisi makanan. Nyeri kepala juga diikuti dengan rasa berat pada tengkuk. tidak ada sensasi seperti berputar. Sesak napas (-). 1 Minggu SMRS • Muntah darah (-). terasa perih dan menyesak. Fotofobia (-). . nyeri bertambah berat setelah makan. konsistensi lunak.gerak (-) 1 Minggu SMRS • Psien juga mengeluhkan badan terasa lemas. kejang (-). lemah ang. kaki bengkak (-). penglihatan kabur (-). tidak ada nyeri dada dan rasa panas di dada. demam (-). hilang kesadaran (-). Nyeri tidak menjalar ke tempat lain. BAK normal dan BAB bewarna hitam sejak 3 hari SMRS.Riwayat Penyakit Sekarang 1 Minggu SMRS • Sejak 1 minggu SMRS pasien mengeluhkan nyeri kepala hebat. Nyeri pada kepala samping (-).

Pasien sangat jarang berolah raga. Riwayat Diabetes Mellitus disangkal. Pasien tidak memiliki kebiasaan merokok. Riwayat penyakit jantung disangkal. Sehari 1 bungkus. RPSos • • • • Pasien adalah seorang buruh angkat. Riwayat penyakit ginjal disangkal. . • Riwayat Diabetes Mellitus dan penyakit jantung disangkal. RPK • Ibu kandung pasien menderita hipertensi yang tidak terkontrol.RPD • • • • Riwayat trauma kepala disangkal. Kebiasaan makan makanan bersantan dan berlemak dengan sedikit sayur dan buah.

Pemeriksaan Fisik Keadaan umum Kesadaran Tekanan Darah Nadi Pernapasan Suhu Berat badan Tinggi badan BMI Status Gizi : tampak lemah : kompos mentis (GCS 15) : 180/100 mmHg : 98 x / menit : 20 x / menit : 36C : 63 kg : 162 cm : 24.2 : Overweigh .

Refleks cahaya kiri=kanan Mulut : Bibir kering (-). . tonsil T1-T1 Leher : JVP 5. pupil isokor. faring tidak hiperemis. pembesaran KGB (-). lidah tidak kotor.Pemeriksaan Fisik Mata : Conjunctiva palpebra inferior pucat (-). sklera ikterik (-). trachea medial.2 cmH2O .

Jantung • Inspeksi: iktus kordis tidak terlihat • Palpasi: iktus kordis teraba 1 jari medial LMCS SIC V • Perkusi: batas jantung kanan : linea strenalis dekstra • Batas jantung kiri: 1 jari medial LMCS SIC V • Auskultasi : Bunyi jantung normal. teratur. bising (-) .

Paru Inspeksi : Dada simetris. ronki (-). wheezing (-) . tidak ada bagian yang tertinggal Palpasi : Vocal premitus kanan = kiri Perkusi : Sonor pada kedua paru. Auskultasi: vesiculer. gerakan dada simetris kiri dan kanan.

Abdomen • Inspeksi : flat. palmar eritem (-) . • Ekstremitas :Akral hangat. shifting dullness (-) • Auskultasi: Bising usus (+) normal. nyeri pada sendi lutut (+). CRT < 2 detik. bengkak pada sendi (-). venektasi (-). edema tungkai (-/-) . NL epigastrium (-). hepar lien tidak teraba. striae (+) • Palpasi : supel. • Perkusi : Timpani. NT (+) epigastrium.

8 gr/dl Hematokrit : 42.800 /μL Trombosit : 421.Pemeriksaan Laboratorium Darah rutin • • • • Hb : 11.1 % Lekosit : 9.000 /μL .

9 mg/dl : 121 mg/dl .Pemeriksaan Laboratorium Kimia Darah • • • • • • AST ALT Alb Chol HDL Trigliserida : 17 IU/L : 31.5 IU/L : 4 mg/dl : 304 mg/dl : 66.

5 mg/dl : 0.9 mg/dl : 23.Pemeriksaan Laboratorium Kimia Darah • • • • • LDL Ureum CRS BUN GDS : 212.58 mg/dl : 11 mg/dl : 112 mg/dl .

• EKG • Ro Thoraks .

muntah (+). laki-laki usia 58 tahun. TD 180/100 mmHg. nyeri ulu hati (+). Dari pemeriksaan fisik didapatkan BMI 24.9 mg/dl . Chol 304 mg/dl. Tengkuk terasa berat (+). lemas (+). mual (+). nyeri bertambah berat setelah makan. ibu kandung menderita hipertensi (+). BAB bewarna hitam sejak 3 hari SMRS. nyeri tekan (+) regio epigastrium. Dari pemeriksaan penunjang di dapatkan.2 (overweight).MS. LDL: 212.Resume Pasien Tn. datang dengan keluhan utama nyeri kepala sejak 1 minggu sebelum masuk rumah sakit. jarang berolahraga (+). sering makan makanan berlemak (+) .

DAFTAR MASALAH Hipertensi Stage II PSCBA Osteoarthritis Dislipidemia Over Weight .

DIAGNOSIS Hipertensi grade II + Ulkus Peptic + Osteoartritis +Dislipidemia .

RENCANA PEMERIKSAAN Urin Rutin USG Ginjal Kadar Asam Urat Darah Funduskopi Endoskopi .

• Turunkan berat badan hingga mencapai BBI .tinggi serat.RENCANA PENATALAKSANAAN Nonmedika mentosa: • Istirahat • Diet rendah garam. rendah lemak.

Omeprazole inj 1x 40 mg Inpepsa syr 2 sdt 3x/hari Celebrex kap 2x 100 mg .RENCANA PENATALAKSANAAN Medika mentosa : IVFD RL 20 tetes/menit Captopril tab 3 X 25 mg Amlodipin tab 1 X 10 mg Simvastatin tab 1x 10 mg.

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