HTN Study Outline

Hypertension in MRCP

Clinical Presentation

Mostly asymptomatic as the majority of cases are primary hypertension. Patient with secondary hypertension presents with the clinical features of causes of hypertension. Additionally, longstanding hypertensive patient can present with complications (Target Organ Damage) of hypertension. Few patients present with occipital headache.

Aims (basic principles) of Investigations in Hypertension

  • To diagnose: ( No Investigation is requires as Hypertension is diagnosed by measuring blood pressure)
  • To identify causes 0f secondary hypertension
  • To identify Target Organ Damage/ complication
  • To identify associated other cardiac risk factors or co morbidities

Management of Hypertension

All the categories of antihypertensive medications are NOT suitable for each patient. Choosing the appropriate antihypertensive drug depends upon following factors-

  1. Age
  2. Race
  3. Causes ( etiology) of hypertension
  4. Existing Target Organ Damage / complication
  5. Associated co morbidities ( eg – pregnancy etc)
  6. Adverse effect of drugs

Target Blood Pressure by Treatment

In general—-   less than 140/90 mm Hg

If age more than 80 years—— less than 150/90 mm Hg

If pregnant——– less than150/100 mm Hg, but if any associated Target Organ Damage- less than 140/90 mm Hg

Additional learning materials

  • DOAMS suggestions
  • DOAMS lecture slides
  • NICE guideline of Hypertension

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DAILY MRCP CHALLENGE – CVS- 2

Sample Question – CVS- 2

A 53-year-old Afro-Caribbean gentleman is diagnosed with hypertension after having three blood pressure measurements greater than 160/100 mmHg. Past medical history is not significant. His BMI is 23, and he looks well. According to the NICE guidelines, which of the following is the most appropriate to prescribe first line for this patient?

(Please select the best option)

  1. Amlodipine Correct
  2. Atenolol
  3. Diltiazem
  4. Ramipril
  5. Valsartan

Patients of African origin are more likely to have low renin hypertension. This means that they are more likely to respond to initial therapy with either a calcium antagonist or diuretic, usually a thiazide. A number of studies have shown that amlodipine is more effective in reducing systolic and diastolic blood pressures

In contrast those patients of Caucasian origin who tend to have higher levels of renin respond much more readily to angiotensin-converting enzyme (ACE) inhibition, or if they fail to tolerate an ACE inhibitor because of cough, to an angiotensin receptor blocker. For these patients, ACE inhibition is seen by NICE as the first line treatment.

ACE inhibitor and calcium antagonist combination has been the one preferred by many clinicians.

 

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DAILY MRCP CHALLENGE – CVS & Nutrition- 1

Sample Question CVS- 1

A 36-year-old patient with recent onset fatigue and prior hypertension presents to the endocrinology clinic as his potassium remains low despite oral supplements. He has no medical history of note.

A full endocrine profile is requested and pending, though the most recent available blood tests demonstrate ongoing hypokalaemia:

Full blood count          normal

Serum sodium 138 mmol/l      (132 – 144)

Serum potassium         2.6 mmol/l       (3.5 – 5.0)

Urea    6.4 mmol/l       (2.5 – 7.5)

Creatinine        70 μmol/l         (50 – 120)

What imaging would you advise now?

(Please choose the best answer)

  1. Abdominal x ray
  2. Barium swallow
  3. Chest x ray
  4. CT abdomen Correct
  5. CT brain

Low potassium with hypertension points toward the diagnosis of primary hyperaldosteronism, or Conn’s syndrome. A more complete biochemical profile would demonstrate alkalosis. The hypokalaemia is often refractory to supplements.

Liddle’s syndrome, a rare genetic abnormality of Na+channels, has a similar clinical presentation of fatigue, hypertension and hypokalaemia, but the sodium is usually higher.

Aldosterone levels are high in Conn’s syndrome and low-normal in Liddle’s syndrome.

CT or MRI of the abdomen identifies a secretory adrenal adenoma, which is usually not evident on abdominal x ray, subsequently managed by adrenalectomy.

CT brain may be indicated in hypokalaemia, with and without hyponatraemia (which may have been corrected too rapidly), to look for central pontine myelinolysis in the very different setting of alcoholic Korsakoff’s syndrome with vitamin and electrolyte deficiencies.

 

 

For further info on STUDY OUTLINE OF HTN, pls CLICK HERE

 

 

 



Picture Challenge 15

Category : Picture Challenge

3rd N Palsy complete

Complete 3rd Nerve Palsy due to surgical cause features with EARLY pupillary abnormality. Pupil will be Dilated and Fixed. Pupillary abnormal response is usually delayed in medical cause of 3rd Nerve palsy

 

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Picture Challenge 14

Category : Picture Challenge

Cluster headache FB OK

Cluster headaches typically involve unilateral excruciating pain which occurs as clusters for a relatively short period of time. There is usually associated lacrimation. Urgent treatment is 100% oxygen inhalation.

Migraine with aura does not present like this.

Trigeminal neuralgia is a definite differential however it usually is associated with face pain and does not involve the eye or come in clusters.

A complicated migraine typically has long tract findings of sensorimotor involvement of the limbs.

 

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Picture Challenge 13

Category : Picture Challenge

Pic 1-  This is the CXR of a 34 year aged lady who presented with cough for 3 month with nocturnal exacerbation with low grade fever, CBC- Hb- 9.9 g/dl, ESR 118, CRP 220, Gene Xpert test for AFB was Negative. This case was treated as a case of RUZ pneumonia with Amoxyclave for 10 days. Patient becomes OK after treatment  and follow up CXR as Pic 2,  and CBC, ESR, CRP all are normal.

Register FREE  in FOPic 1- CXR RUZ shadowPic 2- CXR RUZ Follow upRUM for FURTHER QUERY, DISCUSSION AND COMMENT- CLICK HERE


Picture Challenge 12

Category : Picture Challenge

Its Pompholyx, is a bullous/ vesicular eczematous lesion of hands/foot. It may be a feature of id reaction

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19062009069 Pompholyx FB OK


Picture Challenge 11

Category : Picture Challenge

20120713_170701

This  is Granuloma Annulare,  may be associated with Diabetes or may be idiopathic.  It may be confused with Ring Worm ( Mycosis) but this lesion is  non itchy whereas mycosis is itchy. It is  a self limiting dermatological disease.

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Picture Challenge 10

Category : Picture Challenge

Clubbing with cyanosis in a young boy with Heart problem most likely of Tetralogy of Fallot (TOF).

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