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Hypertension

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55

National Kidney Foundation Primer on Kidney Diseases

The National Kidney Foundation Primer on Kidney Diseases is your ideal companion in clinical nephrology! From anatomy, histology, and physiology, through the diagnosis and management of kidney disease, fluid and electrolyte disorders, hypertension, dialysis, and kidney transplantation, this trusted manual from Elsevier and the National Kidney Foundation provides an accessible, efficient overview of kidney diseases that's perfect for residency, fellowship, clinical practice, and board review. Incorporate the latest NKF Kidney/ Outcome Quality Initiative guidelines on chronic kidney disease staging and management. Review the basics with a current and practical review of the anatomy, physiology, pathophysiology, diagnosis, and management of kidney disease, fluid and electrolyte disorders, hypertension, dialysis, and renal transplantation. Put the latest knowledge to work in your practice with 8 brand-new chapters including kidney development, assessment of kidney function in acute and chronic settings, the kidney in malignancy, acute tubular injury and acute tubular necrosis, acute interstitial nephritis, Fabry Disease, immunosuppression, and transplant infectious disease, as well as comprehensive updates on acute kidney injury, transplant medicine, kidney function and kidney disease in the elderly, GFR estimation, biomarkers in kidney disease, recently described pathologic targets in membranous nephropathy, minimal change disease, viral nephropathies, and much more! Get expert advice from a new team of editors, led by Scott Gilbert and Dan Weiner from Tufts University School of Medicine, each bringing a fresh perspective and a wealth of clinical experience. Quickly access the complete contents online at Expert Consult, with fully searchable text, downloadable images, and additional figures and graphs.  
Google Books
over 4 years ago
Www.bmj
1
19

A 72 old woman with a painful leg after a fall

A 72 year old woman presented to the emergency department after tripping over uneven carpet at home. She had pain in her right groin and was unable to weight bear but had no other injuries. The fall had been a true mechanical one, with no preceding dizziness, chest pain, or palpitations. Her medical history included hypertension, and she had undergone a left (contralateral) total hip replacement four years earlier. Her only regular drug was ramipril. She lived alone, was independent in activities of daily living, and could walk short distances in the community unsupported. She had no ophthalmological disease or other visual impairment.  
bmj.com
over 4 years ago
Www.bmj
1
39

A patient with type 2 diabetes and a burning sensation in his feet

A 64 year old man with type 2 diabetes diagnosed nine years earlier attended the outpatient diabetes clinic because of suboptimal diabetes control. His glycated haemoglobin over the past five years had been 64-77 mmol/mol (8-9.2%; optimal value <53 mmol/mol (7%)). He was being treated for diabetes with gliclazide and metformin. He also received simvastatin and enalapril for dyslipidaemia and hypertension, respectively, and 75 mg acetylsalicylic acid daily for the prevention of primary cardiovascular disease.  
bmj.com
over 4 years ago
Preview
1
28

A case of progressive bilateral pitting oedema

A 68 year old man presented with a two month history of progressive shortness of breath. He had previously been able to swim three times a week, but was now becoming short of breath on climbing stairs. His associated symptoms included orthopnoea, swollen ankles, weight gain, and anorexia. He was being treated with simvastatin for hypercholesterolaemia and diltiazem for hypertension and had never smoked.  
bmj.com
over 4 years ago
Www.bmj
1
14

A collapse with hypertension and hypokalaemia

A 60 year old white man was admitted from the emergency department after an unwitnessed collapse and generalised weakness and malaise. He had no medical history of note and was taking no drugs. On clinical assessment he had hypertension, which had not previously been documented, with a blood pressure of 187/91 mm Hg. Blood tests showed severe hypokalaemia (2.1 mmol/L (reference range 3.6-5.0), having been normal (4.7) nine months earlier) and metabolic alkalosis (bicarbonate 38 mmol/L, 22-30). Random blood glucose was 6.0 mmol/L (3.5-7.8).  
bmj.com
over 4 years ago
Www.bmj
1
18

Multiple enlarging nodules on the lower limb

A 99 year old white woman presented with a 12 month history of nodules and plaques on her left shin. They had been slowly increasing in size and bled intermittently. She denied any history of trauma to her leg and had been systemically well. She reported having high blood pressure and that she had previously had “skin problems” affecting her lower left leg that required surgery. Her only regular drug was bendroflumethiazide, and she had no known drug allergies. She was a non-smoker and drank minimal alcohol. She lived in a ground floor flat and used a walking stick. On review of her medical notes, it was discovered that two areas of squamous cell carcinoma were excised from her left shin 10 years earlier.  
bmj.com
over 4 years ago
Www.bmj
1
30

An abnormality at the hepatic flexure

A 92 year old woman presented to the emergency department after collapsing at home. She recalled standing from her chair, feeling lightheaded, and then collapsing. She had felt generally weak for more than a year, with weight loss of 56 lb (25.2 kg) but no change in bowel habit, dysphagia, or gastrointestinal bleeding. Her medical history included hypertension, hypothyroidism, and anaemia (which was currently being investigated by her general practitioner). Among other drugs, she was taking lisinopril, bendroflumethiazide, and levothyroxine. Her son had died at 60 years of age from large bowel obstruction and perforation secondary to colon cancer.  
bmj.com
over 4 years ago
1
1
66

How does hypertension cause kidney damage?

I can't get my head around the relationship between chronic kidney disease (CKD) and hypertension in diabetes. Does hypertension cause the CKD or does the CKD cause hypertension?  
Clarisse Nirere
almost 7 years ago
10
0
27

Treatment of hypertension in patients with end stage renal failure on haemodialysis?

I heard a renal registrar mention that patients put on haemodialysis who are previously diagnosed with hypertension often don't require pharmacological treatment any more. Why would this be? Is this true?  
Mike Roberts
almost 7 years ago
11
0
31

Are headaches associated with hypertension?

Some people say there is an association between headaches and hypertension. However, I had a lecturer who said that hypertension in the general public is not associated with headaches. Which is correct?  
Alex Catley
almost 7 years ago
10
0
13

Does hypertension correlate more with increased risk of ischaemic heart disease or stroke?

Does hypertension correlate more with increased risk of ischaemic heart disease or stroke? What's the answer and is there a reason why?  
James Wong
over 5 years ago
10
1
27

Investigating hypertension

16 year old male, a secondary school student, arrives in the clinic and you find his blood pressure is 180/80. The history is unremarkable, no systemic symptoms or signs elicited (no headache, visual disturbance,chest pain, dizziness, collapse, urinary symptoms). The examination is normal. No significant previous medical history or family history of hypertension. He is not on any medications. He denies smoking or having taken illicit drugs. BMI is 25. What investigations are you going to order?  
James Wong
over 5 years ago
Foo20151013 2023 2njk5o?1444774020
4
1326

LWW: Case Of The Month - April 2013

This month’s case is by David R Bell PhD, co-author of Medical Physiology: Principles for Clinical Medicine, 3e (ISBN: 9781451110395) For more information, or to purchase your copy, visit: http://tiny.cc/Rhoades4e, with 15% off using the discount code: MEDUCATION. The case below is followed by a quiz question, allowing you a choice of diagnoses. Select the one letter section that best describes the patient’s condition. The Case A 28-year old woman has an unremarkable pregnancy through her first 28 weeks of gestation, with normal weight gain and no serious complications. She has no previous history of diabetes, hypertension of other systemic disease before or during her current pregnancy. During her 30-week checkup, her blood pressure measures 128/85, and she complains about feeling slightly more “bloated” than usual with swelling in her legs that seems to get more uncomfortable as the day goes on. Her obsterician recommends that she get more bed rest, stay off her feet as much as possible and return for evaluation in one week. At the one-week follow-up, the patient presents with noticable”puffiness” in her face, and a blood pressure of 145/95. She complains she has been developing headaches, sporadic blurred vision, right-sided discomfort and some shortness of breath. She has gained more than 10 lb (4.5kg) in the past week. A urinalysis on the patient revelas no glucose but a 3+ reading for protein. Her obstetrician decides to admit her immediately to a local tertiary care hospital for further evaluation. Over the next 24 hours, the patient’s urine output is recorded as 500mL and contains 6.8 grams of protein. Her plasma albumin level is 3.1 g/dl, hemacrit 48%, indirect bilirubin 1.5mg/dl and blood platelets=77000/uL, respectively. Her blood pressure is now 190/100. It is decided to try to deliver the foetus. The expelled placenta is small and shows signs of widespread ischmic damage. Within a week of delivery, the mother’s blood pressure returns to normal, and her oedema subsides. One month later, the mother shows no ill effects of thos later-term syndrome. Question What is the clinical diagnosis of this patient’s condition and its underlying pathophysiology? A. Gestational Hypertension B. Preeclampsia C. Gestational Diabetes D. Compression of the Inferior Vena Cava Answer The correct answer is "B. Preeclampsia". The patient’s symptoms and laboratory findings are consistent with a diagnosis of Preeclampsia, which is a condition occurring in some pregnancies that causes life-threatening organ and whole body regulatory malfunctions. The patient’s negative urine glucose is inconsistent with gestational diabetes. Gestational hypertension or vena caval compression cannot explain all of the patient findings. The patient has three major abnormal findings- generalised oedema, hypertension and proteinuria which are all common in preeclampsia. Although sequalae of a normal pregnancy can include water and salt retention, bloating, modest hypertension and leg swelling (secondary to capillary fluid loss from increased lower limb capillary hydrostatic pressure due to compression of the inferior vena cava by the growing foetus/uterus), oedema in the head and upper extremities, a rapid 10 pound weight gain and shortness of breath suggests a generalized and serious oedematous state. The patient did not have hypertension before or within 20 weeks gestation (primary hypertension) and did not develop hypertension after the 20th week of pregnancy with no other abnormal findings (gestational hypertension). Hypertension with proteinuria occurring beyond the 20th week of pregnancy however is a hallmark of preeclampsia. In addition, the patient has hemolysis (elevated bilirubin and LDH levels), elevated liver enzyme levels and thrombocytopenia. This is called the HELLP syndrome (HELLP = Hemolysis, Elevated Liver enzymes and Low Platelets.), and is considered evidence of serious patient deterioration in preeclampsia. A urine output of 500 ml in 24 hours is 1/2 to 1/4 of normal output in a hydrated female and indicates renal insufficiency. Protein should never be found in the urine and indicates loss of capillaries integrity in glomeruli which normally are not permeable to proteins. The patient has substantial 24 urine protein loss and hypoalbuminemia. However, generally plasma albumin levels must drop below 2.5 gm/dl to decrease plasma oncotic pressure enough to cause general oedema. The patient’s total urinary protein loss was insufficient in this regard. Capillary hyperpermeability occurs with preeclampsia and, along with hypertension, could facilitate capillary water efflux and generalized oedema. However myogenic constriction of pre-capillary arterioles could reduce the effect of high blood pressure on capillary water efflux. An early increase in hematocrit in this patient suggests hemoconcentration which could be caused by capillary fluid loss but the patient’s value of 48 is unremarkable and of little diagnostic value because increased hematocrit occurs in both preeclampsia and normal pregnancy. PGI2, PGE2 and NO, produced during normal pregnancy, cause vasorelaxation and luminal expansion of uterine arteries, which supports placental blood flow and development. Current theory suggests that over production of endothelin, thromboxane and oxygen radicals in preeclampsia antagonize vasorelaxation while stimulating platelet aggregation, microthrombi formation and endothelial destruction. These could cause oedema, hypertension, renal/hepatic deterioration and placental ischemia with release of vasotoxic factors. The patient’s right-sided pain is consistent with liver pathology (secondary to hepatic DIC or oedematous distention). Severe hypertension in preeclampsia can lead to maternal end organ damage, stroke, and death. Oedematous distension of the liver can cause hepatic rupture and internal hemorrhagic shock. Having this patient carry the baby to term markedly risks the life of the mother and is not considered current acceptable clinical practice. Delivery of the foetus and termination of the pregnancy is the only certain way to end preeclampsia. Read more This case is by David R Bell PhD, co-author of Medical Physiology: Principles for Clinical Medicine, 3e (ISBN: 9781451110395) For more information, or to purchase your copy, visit: http://tiny.cc/Rhoades4e. Save 15% (and get free P&P) on this, and a whole host of other LWW titles at (lww.co.uk)[http://lww.co.uk] when you use the code MEDUCATION when you check out! About LWW/ Wolters Kluwer Health Lippincott Williams and Wilkins (LWW) is a leading publisher of high-quality content for students and practitioners in medical and related fields. Their text and review products, eBooks, mobile apps and online solutions support students, educators, and instiutions throughout the professional’s career. LWW are proud to partner with Meducation.  
Lippincott Williams & Wilkins
over 6 years ago
Foo20151013 2023 1eqve0g?1444774030
1
89

LWW: Case Of The Month - May 2013

This month’s case is by Barbara J. Mroz, M.D. and Robin R. Preston, Ph.D., author of Lippincott’s Illustrated Reviews: .Physiology (ISBN: 9781451175677). For more information, or to purchase your copy, visit: http://tiny.cc/PrestonLIR, with 15% off using the discount code: MEDUCATION. The case below is followed by a choice of diagnostic tests. Select the one lettered selection that would be most helpful in diagnosing the patient’s condition. The Case A 54-year-old male 2 pack-per-day smoker presents to your office complaining of cough and shortness of breath (SOB). He reports chronic mild dyspnea on exertion with a daily cough productive of clear mucus. During the past week, his cough has increased in frequency and is now productive of frothy pink-tinged sputum; his dyspnea is worse and he is now short of breath sometimes even at rest. He has had difficulty breathing when lying flat in bed and has spent the past two nights sleeping upright in a recliner. On physical examination, he is a moderately obese male with a blood pressure of 180/80 mm Hg, pulse of 98, and respiratory rate of 22. His temperature is 98.6°F. He becomes winded from climbing onto the exam table. Auscultation of the lungs reveals bilateral wheezing and crackles in the lower posterior lung fields. There is pitting edema in the lower extremities extending up to the knees.  Question Which if the following tests would be most helpful in confirming the correct diagnosis? A. Spirometry B. Arterial blood gas C. Complete blood count D. B-type natriuretic peptide blood test E. Electrocardiogram Answer? The correct answer is B-type natriuretic peptide blood test. Uncomfortable breathing, or feeling short of breath, is a common medical complaint with multiple causes. When approaching a patient with dyspnea, it is helpful to remember that normal breathing requires both a respiratory system that facilitates gas exchange between blood and the atmosphere, and a cardiovascular system that transports O2 and CO¬2 between the lungs and tissues. Dysfunction in either system may cause dyspnea, and wheezing (or bronchospasm) may be present in both cardiac and pulmonary disease. In this patient, the presence of lower extremity edema and orthopnea (discomfort when lying flat) are both suggestive of congestive heart failure (CHF). Elevated blood pressure (systolic of 180) and a cough productive of frothy pink sputum may also be associated symptoms. While wheezing could also be caused by COPD (chronic obstructive pulmonary disease) in the setting of chronic tobacco use, the additional exam findings of lung crackles and edema plus systolic hypertension are all more consistent with CHF. What does the B-type natriuretic peptide blood test tell us? When the left ventricle (LV) fails to maintain cardiac output (CO) at levels required for adequate tissue perfusion, pathways are activated to increase renal fluid retention. A rising plasma volume increases LV preload and sustains CO via the Frank-Starling mechanism. Volume loading also stimulates cardiomyocytes to release atrial- (ANP) and B-type (BNP) natriuretic peptides. BNP has a longer half-life than ANP and provides a convenient marker for volume loading. Plasma BNP levels are measured using immunoassay; levels >100 pg/mL are suggestive of overload resulting in heart failure. How does heart failure cause dyspnea? Increasing venous pressure increases mean capillary hydrostatic pressure and promotes fluid filtration from the vasculature. Excess filtration from pulmonary capillaries causes fluid accumulation within the alveoli (pulmonary edema) and interferes with normal gas exchange, resulting in SOB. Physical signs and symptoms caused by high volume loading include: (1) Lung crackles, caused by fluid within alveoli (2) Orthopnea. Reclining increases pulmonary capillary hydrostatic pressure through gravitational effects, worsening dyspnea when lying flat. (3) Pitting dependent edema caused by filtration from systemic capillaries, an effect also influenced by position (causing edema in the lower legs as in our ambulatory patient or in dependent areas like the sacrum in a bedridden patient). What would an electrocardiogram show? Heart failure can result in LV hypertrophy and manifest as a left axis deviation on an electrocardiogram (ECG), but some patients in failure show a normal ECG. An ECG is not a useful diagnostic tool for dyspnea or CHF per se. Wouldn’t spirometry be more suitable for diagnosing the cause of dyspnea in a smoker? Simple spirometry will readily identify the presence of airflow limitation (obstruction) as a cause of dyspnea. It's a valuable test to perform in any smoker and can establish a diagnosis of chronic obstructive pulmonary disease (COPD) if abnormal. While this wheezing patient is an active smoker who could have airflow obstruction, the additional exam findings above point more to a diagnosis of CHF. What would an arterial blood gas show? An arterial blood gas measures arterial pH, PaCO¬2, and PaO2. While both CHF and COPD could cause derangements in the values measured, these abnormalities would not necessarily be diagnostic (e.g., a low PaO2 could be seen in both conditions, as could an elevated PaCO¬2). Would a complete blood count provide useful information? A complete blood count could prove useful if anemia is a suspected cause of dyspnea. Test result BNP was elevated (842 pg/mL), consistent with CHF. Diuretic treatment was initiated to help reduce volume overload and an afterload reducing agent was started to lower blood pressure and improve systolic function.  
Lippincott Williams & Wilkins
over 6 years ago
Foo20151013 2023 1fhdw5v?1444774091
0
92

The Arterial Highway

Metaphors and analogies have long been used to turn complex medical concepts into everyday ones, albeit with fancy terminology. Having been involved with many 3D animations on the topics of Blood Pressure, arteriosclerosis, cholesterol and the like, we find that often a metaphor goes a long way to building understanding, credibility and even compliance with patients. One of my favorite analogies is what we call the arterial highway. Much like their tarmacked counterparts, arteries act as conduits for all the parts that make your body go. A city typically uses highways, gas lines, water pipes, railways and other infrastructure to distribute important materials to its people. Your body is much the same, except that it does it all in one system, the cardiovascular system. This is used to deliver nutrients, extract waste, transport and deliver oxygen and even to maintain the temperature! The arteries can do all these things because of their smart three-layered structure. Our arteries consist of a muscular tube lined by smooth tissue. They have three layers named – the Adventitia, Media and Intima. Each is designed with a specific function and through the magic of evolution has developed to perform its function perfectly. The first is the Tunica Adventitia, or just adventitia. It is a strong outer covering over the arteries and veins. It has special tissues that are fibrous. The fibers let the arteries flex, expanding and contracting to accommodate changes in blood pressure as the blood flows past it. Unlike a steel pipe, arteries pulsate and so must be at once be flexible, and strong. Tunica Media - the middle layer of the walls of arteries and veins is made up of a smooth muscle with some elasticity built in. This layer expands and contracts in a rhythmic fashion, much like a Wave at a baseball game, as blood moves along it. The media layer is thicker in arteries than in veins, and importantly so, as arteries carry blood at a higher pressure than veins. The innermost layer of arteries and veins is the Tunica Intima. In arteries, this layer is composed of an elastic lining and smooth endothelium - a thin sheet of cells that form a type of skin over the surface. The elastic tissue present in the artery can stretch and return, allowing the arteries to adapt to changes in flow and blood pressure. The intima is also a very smoothe, slick layer so that blood can easily flow past it. Every layer of the artery has developed evolutionary traits that help your arterial system to maintain flexibility, strength and promote blood flow. Diseases and conditions like high cholesterol or high blood pressure, diabetes and others prevent the arteries from doing their function well by creating blockages or increasing the stress on one or more of the layers. For example, high blood pressure causes rips in the smooth lining of the Intima. Anybody who has experienced a pipe burst in a house knows that the damage can be extreme and can never fully be restored. Understanding the delicate functions of the arterial structure gives good incentive to treat them better. Conditions like high blood pressure, high cholesterol and lifestyle diseases such as diabetes create tears, holes, blockages, and can disrupt the functions of one or more layers. Getting patients to visualize the effect of bad eating habits on their anatomy helps to increase patient compliance. In modern society, the concept of highways goes hand in hand with the concept of traffic jams. Patients understand that the arterial highway is one that can never be jammed.  
Mr. Rohit Singh
about 6 years ago
Preview
0
21

A case of progressive bilateral pitting oedema

A 68 year old man presented with a two month history of progressive shortness of breath. He had previously been able to swim three times a week, but was now becoming short of breath on climbing stairs. His associated symptoms included orthopnoea, swollen ankles, weight gain, and anorexia. He was being treated with simvastatin for hypercholesterolaemia and diltiazem for hypertension and had never smoked.  
feeds.bmj.com
over 4 years ago
Www.bmj
0
16

A collapse with hypertension and hypokalaemia

A 60 year old white man was admitted from the emergency department after an unwitnessed collapse and generalised weakness and malaise. He had no medical history of note and was taking no drugs. On clinical assessment he had hypertension, which had not previously been documented, with a blood pressure of 187/91 mm Hg. Blood tests showed severe hypokalaemia (2.1 mmol/L (reference range 3.6-5.0), having been normal (4.7) nine months earlier) and metabolic alkalosis (bicarbonate 38 mmol/L, 22-30). Random blood glucose was 6.0 mmol/L (3.5-7.8).  
feeds.bmj.com
over 4 years ago
Www.bmj
0
13

Multiple enlarging nodules on the lower limb

A 99 year old white woman presented with a 12 month history of nodules and plaques on her left shin. They had been slowly increasing in size and bled intermittently. She denied any history of trauma to her leg and had been systemically well. She reported having high blood pressure and that she had previously had “skin problems” affecting her lower left leg that required surgery. Her only regular drug was bendroflumethiazide, and she had no known drug allergies. She was a non-smoker and drank minimal alcohol. She lived in a ground floor flat and used a walking stick. On review of her medical notes, it was discovered that two areas of squamous cell carcinoma were excised from her left shin 10 years earlier.  
feeds.bmj.com
over 4 years ago
Preview
0
15

An abnormality at the hepatic flexure

A 92 year old woman presented to the emergency department after collapsing at home. She recalled standing from her chair, feeling lightheaded, and then collapsing. She had felt generally weak for more than a year, with weight loss of 56 lb (25.2 kg) but no change in bowel habit, dysphagia, or gastrointestinal bleeding. Her medical history included hypertension, hypothyroidism, and anaemia (which was currently being investigated by her general practitioner). Among other drugs, she was taking lisinopril, bendroflumethiazide, and levothyroxine. Her son had died at 60 years of age from large bowel obstruction and perforation secondary to colon cancer.  
feeds.bmj.com
over 4 years ago
Preview
2
59

Hypertension Explained Clearly | 2 of 2

A clear explanation of the medications used to treat hypertension by Dr. Seheult. He details some of the less commonly used medications for hypertension incl...  
youtube.com
over 4 years ago