3.3 Approach to the Pt Diagnosed w/ Hypertension
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What is 1° hypertension for physical exams?
- General appearance, skin lesions, distribution of body fat (Metabolic syndrome - obesity)
- Exam neck for thyroid enlargement, carotid bruits (Hyperthyroidism - diffuse goiter)
- Cardiopulm exam (target organ damage - cardiac gallop)
- Abdominal exam (polycystic kidney disease - palpable kidneys, renal artery disease - mid-epigastric bruits)
- Neuro exam (signs of previous stroke - gait disturbance, hyperreflexia, Babinski sign)
- Pulse exam (coarctation of the aorta - delayed or absent femoral pulses)
What is 1° hypertension for hx?
- Onset 20-50 yo
- Diet - significant salt intake, alcohol, tobacco
- Family hx
- Nonsteroidal anti-inflammatory drugs, oral contraceptives, cough meds
- Sleep apnea - snoring and daytime somnolence
- Hyperthyroid - heat intolerance and weight loss
- Coronary artery disease - chest pain
What is 2° hypertension like using hx and physical exam?
- Onset <20 or >50 yo
- No family hx
- Acute onset, severe, refractory
- Signs, symptoms, labs of target organ damage
What are the signs/ symptoms of Coarctation of the Aorta?
- Arm to leg sbp difference >20 mmHg
- Delayed or absent femoral pulses
- Young, cold feet, leg pain w/ exercise
What are the diagnostic tests to have for Coarctation of the Aorta?
- MRI (adults)
- Transthoracic echocardiography (children)
What are the CV etiologies of secondary HTN?
Coarctation of the Aorta - narrowing of the descending aorta between the upper-body artery branches and the branches to the lower body
What are the Neurological etiologies of secondary HTN?
- Obstructive Sleep Apnea - sleeper has repeated episodes of apnea due to a blocked airway
- Snoring is interrupted by short periods of apnea
- Excessive daytime sleepiness (EDS)
What are some tests you can do for Obstructive Sleep Apnea?
- Epworth Sleepiness Scale
- Polysomnography (sleep study)
- Apnea/ Sleepiness Score w/ nighttime pulse oximetry
What are some signs/ symptoms of Obstructive Sleep Apnea?
- Apneic events during sleep
- Daytime sleepiness
What are the Renal (Parenchymal) etiologies of secondary HTN?
- Glomerulonephritis - damage to the renal parenchyma is the most common cause of hypertension in preadolescent children
- Kidneys ability to excrete salt and excess fluid decreases
What are diagnostic tests for Renal Parenchymal Disease (Glomerulonephritis)?
- Blood urea nitrogen, creatinine
- Urinalysis, urine culture
- Renal ultrasound
What are the signs/ symptoms for Renal Parenchymal Disease (Glomerulonephritis)?
- Foamy urine
What are signs/ symptoms of Renal Artery Stenosis?
- Renal bruit
- Worsening in blood pressure in chronic hypertension
- Marked change (decrease) in adult kidney size
What are diagnostic tests for Renal Artery Stenosis?
- Doppler ultrasonography of renal arteries
What are the Renal (Renovascular) etiologies of secondary HTN?
- Renal Artery Stenosis (RAS) - vascular disorder of unknown etiology that causes narrowing of the renal artery that leads to decreased renal perfusion.
- Fibromuscular Dysplasia - "beads on a string"
- Atherosclerosis - suspect in newly dx hypertensives >= 50 yo
What are the signs/ symptoms for Pheochromocytoma?
- Labile blood pressure
What are the diagnostic tests for Pheochromocytoma?
- 24-hr urinary fractionated metanephrines
- Plasma free metanephrines
What are the Endocrine/ metabolic etiologies of secondary HTN?
- Cushing Syndrome (hypercortisolism) - almost always iatrogenic from prescribed corticosteriods
- Pheochromocytoma - catecholamine (hormones from adrenal glands) secreting tumors. Most predominalty secrete NE. Sustained or paroxysmal HTN. Classic Triad: H/a, perspiration, palpitations
- Hyperaldosteronism (Conn's Syndrome) - aldosterone producing adenoma
What are diagnostic tests for Cushing Syndrome?
- 24-hour urinary cortisol
- Late-night salivary cortisol
What are signs/ symptoms of Cushing Syndrome?
- Purple striae
- Buffalo hump
- Moon facies
- Central Obesity
What lab and radiologic workups would you get to correctly dx and assess for possible organ damage?
- Hemoglobin or hematocrit (Part of CBC)
- Urinalysis w/ microscopic exam - checking kidneys
- Serum electrolyte concentrations
- Serum creatinine concentrations
- Serum glucose concentrations
- Fasting lipid profile
- 12-lead ECG - looking for end organ damage
What are signs/ symptoms for Primary Aldosteronism (Hyperaldosteronism; Conn's Syndrome)
- Resistant Hypertension
- Metabolic Acidosis
What are diagnostic tests for Primary Aldosteronism (Hyperaldosteronism; Conn's Syndrome)?
Renin and aldosterone levels to calculate aldosterone/ renin ratio
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