3.3 Approach to the Pt Diagnosed w/ Hypertension

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3.3 Approach to the Pt Diagnosed w/ Hypertension
2014-01-23 03:53:28
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  1. What is 1° hypertension for physical exams?
    • General appearance, skin lesions, distribution of body fat (Metabolic syndrome - obesity)
    • Funduscopy
    • 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)
  2. What is 1° hypertension for hx?
    • Onset 20-50 yo
    • Diet - significant salt intake, alcohol, tobacco
    • Inactivity
    • 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
  3. 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
  4. What are the signs/ symptoms of Coarctation of the Aorta?
    • Arm to leg sbp difference >20 mmHg
    • Delayed or absent femoral pulses
    • Murmur
    • Young, cold feet, leg pain w/ exercise
  5. What are the diagnostic tests to have for Coarctation of the Aorta?
    • MRI (adults)
    • Transthoracic echocardiography (children)
  6. 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
  7. 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)
  8. What are some tests you can do for Obstructive Sleep Apnea?
    • Epworth Sleepiness Scale
    • Polysomnography (sleep study)
    • Apnea/ Sleepiness Score w/ nighttime pulse oximetry
  9. What are some signs/ symptoms of Obstructive Sleep Apnea?
    • Apneic events during sleep
    • Daytime sleepiness
    • Snoring
  10. 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
  11. What are diagnostic tests for Renal Parenchymal Disease (Glomerulonephritis)?
    • Blood urea nitrogen, creatinine
    • Urinalysis, urine culture
    • Renal ultrasound
  12. What are the signs/ symptoms for Renal Parenchymal Disease (Glomerulonephritis)?
    • Preadolescents
    • Edema
    • Foamy urine
  13. What are signs/ symptoms of Renal Artery Stenosis?
    • Renal bruit
    • Worsening in blood pressure in chronic hypertension
    • Marked change (decrease) in adult kidney size
  14. What are diagnostic tests for Renal Artery Stenosis?
    • MRI
    • CT
    • Doppler ultrasonography of renal arteries
  15. 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
  16. What are the signs/ symptoms for Pheochromocytoma?
    • H/a 
    • Palpitations
    • Perspiration
    • Labile blood pressure
  17. What are the diagnostic tests for Pheochromocytoma?
    • 24-hr urinary fractionated metanephrines
    • Plasma free metanephrines
  18. What are the Endocrine/ metabolic etiologies of secondary HTN?
    • Obesity
    • 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
  19. What are diagnostic tests for Cushing Syndrome?
    • 24-hour urinary cortisol
    • Late-night salivary cortisol
  20. What are signs/ symptoms of Cushing Syndrome?
    • Purple striae
    • Buffalo hump
    • Moon facies
    • Central Obesity
  21. 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
  22. What are signs/ symptoms for Primary Aldosteronism (Hyperaldosteronism; Conn's Syndrome)
    • Hypokalemia
    • Hypernatremia
    • Resistant Hypertension
    • Metabolic Acidosis
  23. What are diagnostic tests for Primary Aldosteronism (Hyperaldosteronism; Conn's Syndrome)?
    Renin and aldosterone levels to calculate aldosterone/ renin ratio