Topic #1: Management of patients with arterial hypertension.

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1. Name 10 the most frequent complications of arterial hypertension:

1. Stroke
_________________________ CHD
6. ____________________________
2. Right sided heart failure
_________________________ Malignant hypertension
7. ____________________________
3. Left ventricle hypertrophy
_________________________ CHD
8._____________________________
4. Cerebro vascular disease
_________________________ MI
9._____________________________
5. Arrhythmia
_________________________ 10.____________________________
Retinopathy

2. What is the expected risk to die of cardiovascular disease according to the SCORE scale:

1) for the smoking man of 65 years with an average systolic BP of 180 mm. Hg. and with total cholesterol 8 mmol/l
47%
in the nearest 10 years? __________%

2) for the non-smoking woman of 47 years with an average systolic BP of 160 mm. Hg. and with total cholesterol
1%
6,5 mmol/l in the nearest 10 years?__________%

3) for the non-smoking man of 45-th years with an average systolic BP of 140 mm. Hg. and with total cholesterol
6,0 mmol/l in the nearest 10 years? __________%
1-2%

4) for the smoking woman of 55-th years with an average systolic BP of 160 mm. Hg. and with total cholesterol
5%
8 mmol/l in the nearest 10 years? __________%

3. Name the ECG signs which can specify in the presence of arterial hypertension.
ST SEGMENT INVERTION , T WAVE INVERSION IN V1-V3 , QRS > 12 s ,
____________________________________________________________________________________________
R wave > 7
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

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Homework assignment is written and translated by Medianka J.S., Department of Internal Medicine #4
 4.Clinical task.
Patient M., 53-th years, protractedly suffering AH, appealed to his general practitioner with complains of
headache in a cervical area, dizziness, periodic sense of nausea, decline of sight. During last 5 years suffers from
diabetes mellitus of type 2. He does not smoke, drinks little alcohol, and has sadentiary life style.
On examination: obese. Skin is pale, moist. Cyanosys of lips. Respiratory system: normal findings. Pulse 78 in a
minute, rhythmic, satisfactory filling. BP 170/90 mm. Hg. Heart borders: right - on the right edge of breastbone,
left - 1 cm left from a left midclavicular line. Heart tones are muffled, noises are absent. A stomach is soft, painless.
A liver and spleen not palpable.
À) Specify key symptoms and objective signs of arterial hypertension:
____________________________________________________________________________________________
Headache , obesity , dizziness , nausea , decline sight
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

B) Specify a preliminary clinical diagnosis:

____________________________________________________________________________________________
Stage 2 hypertension
____________________________________________________________________________________________
With comorbidity of DM type 2
____________________________________________________________________________________________
C. What instrumental and laboratory investigations will you appoint and for what purpose?
Instrumental:
Echocardiography
____________________________________________________________________________________________
____________________________________________________________________________________________
Laboratory:
____________________________________________________________________________________________
Lipid test , fasting blood sugar , serum electrolytes , bun and serum ,
creatinine level
____________________________________________________________________________________________
____________________________________________________________________________________________

D. Describe the presented cardiogram of patient I.:

Left ventricle hypertrophy

E. Blood analysis of patient I.:

Index Result Norm Index Result Norm
Glucose 8,0 mmol/l 3,3-6,1 mmol/l HDLC 0,5 mmol/l > 1 mmol/l
Creatinine 0,100 mmol/l 0,044-0,104 mmol/l LDLC 5,0 mmol/l < 3 mmol/l
General bilirubine 18 mkmol/l 1,7-25,5 mkmol/l VLDLC 1,3 mmol/l 0,26 – 1,05
mmol/l
Triglycerides 3,2 mmol/l 0,14-1,77 mmol/l Total cholesterol 6,1 mmol/l 3,1-5,2 mmol/l
Describe a blood test of patient I.:
 Glucosee inc , creatinine upper border limit , triglycerides high , HDL low ,
____________________________________________________________________________________________
LDL high , VLDL high , total chol high
____________________________________________________________________________________________
____________________________________________________________________________________________

F. Write the treatment plan of patient I.:

Non-medical:
____________________________________________________________________________________________
Life style modification
Low NA intake , high K diet
____________________________________________________________________________________________
Physical activity
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Medicinal:
Drug therapy:
____________________________________________________________________________________________
We can start TX with ACE inhibitors/ARBS because he is under 55 , and if
not seen any progress than use of combination of ACEI + calcium channel
____________________________________________________________________________________________
blockers, if still we can add diuretics .
____________________________________________________________________________________________
For diabetes anti lipidimic drugs
____________________________________________________________________________________________
____________________________________________________________________________________________

5. Clinical task.
A woman 36 years old complains of headache, paresthesias, muscle weakness, cramps, increased thirst and
nocturia. On examination: temperature - 36,6 C°, RR - 18 in mins, pulse - 92 in a minute, BP 180/110 мм Hg. Obese.
On ECG - STsegment depression in lateral leads.

A. Describe results of analysis of patient:

Index Result Norm
Potassium 2,1 3,5-5,0 mmol/l
Sodium 181 135-145 mmol/l
Renin 1,8 4,4 - 46,1 mkME/ml
Aldosterone 35 2-16 ng/100 ml
Hyper aldosterone Renin is low
______________________________________________________________________________________________
K+ is low and Na+ is high
______________________________________________________________________________________________

B. What does a positive spironolactons test mean for this patient?

______________________________________________________________________________________________
Decrease in Na and increase in K in blood thats leads to normalization of
______________________________________________________________________________________________
symptoms
______________________________________________________________________________________________

C. Specify a preliminary clinical diagnosis:

Hypertension stage 2
______________________________________________________________________________________________
Hyper aldosterone ( primary)
______________________________________________________________________________________________

D. What instrumental investigations will you appoint to this patient and for what purpose?
______________________________________________________________________________________________
X ray of kidney
CT scan of kidney
______________________________________________________________________________________________
______________________________________________________________________________________________

E. Describe urinalysis by Zimnicki of this patient:

Daily diuresis Night diuresis
Time of urine Volume, ml. Relative density Time of urine Volume, ml. Relative density
sample, h. of urine sample, h. of urine
9 200 1011 21 100 1009
12 200 1010 24 180 1008
15 250 1008 3 - -
18 250 1010 6 100 1011

____________________________________________________________________________________________
________________________________________________________________________
Daily have more urine output than at night
__________________________________________________________________________________
F. Write treatment plan:
Aldosterone antagonist-spironolactone
____________________________________________________________________________________________
Epleronone ( k sparing diuretic)
____________________________________________________________________________________________
Ace inhibitors
______________________________________________________________
Calcium channel blockers
____________________________________________________________________________________________
________________________________________________________________________

6. List basic hypotensive preparations and contra-indications to their admission:

Medications: Contra-indications to their use:
ACE inhibitors
Acute coronary syndrome-postMI Pregnancy
Diabetic nephropathy Renal artery stenosis
Hypertension Hyperkalemia

ß-blokers
Congestive heart failure due to
systolic malfunction
Chronic stable angina DM
Asthma
Av block

Calcium channel blokers

Cardiomyopathy
HTN Hypotension
Subarachnoid hemorrhage Sick sinus syndrome
Pulmonary congestion
Acute MI

Diuretics
Pulmonary
Glaucoma Edema
Hypercalcemia Liver disease
HTN Acute renal failure

Angiotensin-II receptor blockers

HTN
Decrease insulin resistance Pregnancy
Renal artery stenosis