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Hypertension: Pathology review

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Hypertension: Pathology review

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Questions

USMLE® Step 1 style questions USMLE

3 questions
Preview

A 60-year-old man comes to the physician office due decreased vision, progressive fatigue and swelling around the ankles for the past 4 weeks. Medical history is significant for myocardial infarction 2 years ago, diabetes mellitus type 2 and hypertension. Current medications include aspirin, captopril, metformin and lovastatin. Temperature is 36.4°C (97.5°F), pulse is 80/min, and blood pressure is 144/90 mmHg.  Physical examination shows 2+ edema around the ankles bilaterally. Fundoscopic examination reveals retinal arteriolar narrowing, arteriovenous nicking, and flame-shaped hemorrhages. Laboratories studies are shown: 




Which of the following is likely responsible for this patient’s eye examination findings?

Transcript

Anthony is a 40 year old male with a history of type 2 diabetes mellitus presenting to a family medicine clinic for his annual health check-up. His blood pressure measurement is 145 over 95 millimeters of mercury, and his BMI is 32. On further history, he explains that his job as a truck driver has prevented him from exercising regularly. His father had a history of hypertension and passed away from a stroke. A follow-up appointment showed a blood pressure of 150 over 90. Alicia is a 30 year old female who came in because she’s concerned that she might be pregnant. Her pregnancy test is negative, however, her blood pressure is 170 over 90. On her second appointment, her blood pressure remains elevated. She is placed on lisinopril. A couple of days later, she presents with decreased urine output, and an elevated blood urea nitrogen and creatinine. Finally, Vikander is a 62 year old-male with a history of hypertension. He complains of headache, altered mental status, and visual changes. On further history, he mentions he is “sick of all the medications he has to take”. Fundoscopic examination reveals a swollen optic disk, and his blood pressure is 200 over 120.

Okay so all three people present with hypertension. Now normal blood pressure is less than 120 systolic over 80 diastolic. According to the recent 2017 American Heart Association and American College of Cardiology guidelines, hypertension is currently defined as a blood pressure over 130 systolic and 80 diastolic. Now, typically, both systolic and diastolic pressures tend to rise or fall together, but that’s not always the case. Sometimes, you can have systolic or diastolic hypertension. This is referred to as isolated systolic hypertension or isolated diastolic hypertension.

Okay, just because you see an elevated blood pressure on the exam, it does not mean that individual has hypertension. The blood pressure must be persistently elevated in order to define it as hypertension. So on your exam, remember that the diagnosis requires at least 2 separate readings on 2 separate visits. The reason for this is because of the phenomenon of “white coat hypertension”. This is hypertension on physical exam that occurs because of anxiety experienced by the individual.

Hypertension is classified into primary, or essential hypertension, and secondary hypertension. Primary hypertension occurs without a known secondary cause, and accounts for 90 percent