Image of the Week 12/16/2014

What common incidental finding can be seen on this CT scan performed as part of an evaluation for abdominal pain and diarrhea on a 57-year old man?

Primary Hypertension

Our talk this evening was given by Jake Decker, PGY2 in Primary Care on a specific facet of hypertension discussed the previous week: Primary Hypertension.

Case:

A 58 y/o M with no significant PMH comes in with an elevated BP of 148/88 today.

HTN Definition and Goals:

• Elevated BP: a reading of elevation or not.
• HTN: a diagnosis, disease state. The average of 2+ properly measured reading at each of two or more visits after initial screen.
• Clinically we use these guidelines of whether patients are at these goals:
• ages 18-59: <140/<90
• ages >60: <150/<90

• DM (all ages): 
• <140/<90 because of comorbidities
• Cutoff still controversial because not sure if want to be aggressive with older patients' BP because it might be harmful.
• Kidney disease (all ages): <140/<90

HPI:

• Diet, obesity
• Episodic/constant
• Associated with other conditions?
• Recent caffeine intake
• Kidney problems
• What meds patients is on (NSAIDs, steroids, SSRIs, TCAs, OCPs)
• Smoking, alcohol, and cocaine use (raises BP)
• HA, dizziness
• Vision change
• chest pain, palpitations
• snoring, daytime tiredness
• Sweating, tremors

Physical exam: 

• General impressions
• Take vitals at least twice
• Eye exam (retinal hemorrhages)
• Vascular exam (asymmetric or diminished pulses)
• Cardiac (stenosis, dilated heart muscle)
• Lungs (crackles)
• Basic metabolic panel; creatnine reading to assess end organ damage.
• Urinalysis; CKD can cause HTN, chronic HTN causes CKD.
• EKG: conduction abnormalities, previous/current ischemia or infarction, LV hypertrophy.

Treatment:

• 1) Lifestyle modification 
• Diet/exercise, quitting smoking/drinking. 
• Dash and Mediterranean diets are most largely studied for HTN. 
• Limit sodium to <2400 mg/daily.  
• If end organ damage and reading of 160/90, skip to step 2.

• 2) Pharmacotherapy
• Thiazide diuretics
• Calcium channel blockers
• ACE inhibitors
• ARBs
• For non-black patients: all equal choices
• For black patients: thiazide or CCB
• For CKD patients: ACEi or ARB because they reduce pressure in glomerulus.
• For women of childbearing age: CCB

Hypertension: Another Way to Look at It

Tonight's talk was delivered by Tomi Jun, MS IV on the hypertension areas we can pay attention to specifically in the CCC clinic.

Hypertension cutoffs:

• Stage 1: >140/90
• Stage 2: >160/100

Method:

• 3 measurements, each 1 week apart.
• Consistent pattern.
• Be mindful of activity and white coat measurements.

Primary HTN: treating HTN directly

Secondary HTN: Blood pressure elevated because of secondary causes like a tumor that secretes epinephrine (rare case). The treatment is not to manage the BP but to remove the tumor.

When BP is >180/120:

• Hypertensive urgency: Regular checkup finding asymptomatic HTN. 
• Emergency: when people are showing symptoms like chest pain, altered mental status. If people have a high BP but asymptomatic we still want to send them to the ER.

What we are worried about

•  End organ damage
• Brain
• Heart
• Kidneys
• Vasculature
• Long term damage

________________________________________________________________________
Atherosclerosis: 

• injury to vasculature. 
• plays role in other areas of HTN. 
•  Buildup over time leading to lack of oxygen or rupture
• Achemia and strokes occur. 
• Coronary artery disease occurs, which leads to...

Heart disease: 

• Heart attack leads to heart failure
• Left ventricular hypervole: thickening of left ventricle. The muscle gets bigger and stiffer as it pumps against high systemic resistance.

Kidney disease:

• HTN big risk factor for end stage renal disease --> dialysis. 
• HTN makes substances squeeze through kidney vessels, damaging them.

________________________________________________________________________

Case 1:

• 50 yo F African American with obesity, HTN, DM.
• BP 150/90
• BMI 45.1
• 3 HTN meds: metropolol, losartan, chlotalidone
• Worried about: risk factors such as smoking and DM for kidney disease, heart failure, athero, and stroke.
• Think about changing metropolol to a medication that acts upon calcium channels.

JNC8 Guidelines:

• For people <60, goal is >150/90
• Previously 140/90 from JNC7
• Recently found that there is no additional benefit from goal of 140/90, which takes more meds to achieve.

Lifestyle modification:

• Weight reduction: every 10 kg lost can bring down diastolic BP by 20. 
• Cut dietary salt, reduce alcohol intake, exercise.

________________________________________________________________________

What to ask:

• Meds adherence
• PMH
• Lifestyle (smoking, exercise, diet, alcohol)
• Symptoms (cardiac, neuro)

What to examine:

• Signs of heart failure
• Fundoscopy
• Labs
• basic metabolic panel
• kidney function
• electrolytes
• lipid profile
• urinalysis
• screen/eval DM
• Look for evidence of end-organ damage or other relevant risk factors.

Image of the Week 12/02/2014

Which genetic disorder would this X-ray of the lungs be associated with?