ICM Patient With Hypertension

1. Mrs. Gonzales is a 31 year old Hispanic female at 34 weeks gestation who presents to labor and delivery with complaints of a frontal headache and blurred vision. She has a blood pressure of 150/98, generalized edema, and 4+ proteinuria. The most likely cause of her clinical situation is:

Conn’s syndrome

Transient hypertension of pregnancy

Eclampsia

Benign hypertension

Pre-eclampsia

Pre-eclampsia is diagnosed when a pregnant woman develops high blood pressure (two separate readings taken at least six hours apart of 140 or more in systolic blood pressure and/or 90 or more in diastolic blood pressure) and 300 mg of protein in a 24-hour urine sample (proteinuria). A rise in baseline blood pressure (BP) of 30 mmHg systolic or 15 mmHg diastolic, while not meeting the absolute criteria of 140/90, is still considered important to note, but is not considered diagnostic.

"Severe pre-eclampsia" involves a BP over 160/110[2][3] with additional symptoms.

[edit] Other symptoms

Swelling or edema (especially in the hands and face) was originally considered an important sign for a diagnosis of pre-eclampsia, but in current medical practice only hypertension [4] and proteinuria are necessary for a diagnosis. Pitting edema (unusual swelling, particularly of the hands, feet, or face, notable by leaving an indentation when pressed on) can be significant, and should be reported to a health care provider.

Explanation

Pre-eclampsia is diagnosed when a pregnant woman develops high blood pressure (two separate readings taken at least six hours apart of 140 or more in systolic blood pressure and/or 90 or more in diastolic blood pressure) and 300 mg of protein in a 24-hour urine sample (proteinuria). A rise in baseline blood pressure (BP) of 30 mmHg systolic or 15 mmHg diastolic, while not meeting the absolute criteria of 140/90, is still considered important to note, but is not considered diagnostic.

"Severe pre-eclampsia" involves a BP over 160/110[2][3] with additional symptoms.

[edit] Other symptoms

Swelling or edema (especially in the hands and face) was originally considered an important sign for a diagnosis of pre-eclampsia, but in current medical practice only hypertension [4] and proteinuria are necessary for a diagnosis. Pitting edema (unusual swelling, particularly of the hands, feet, or face, notable by leaving an indentation when pressed on) can be significant, and should be reported to a health care provider.

2. A 45 year old female presented to her family physician with obesity, abdominal striae, headache, and a blood pressure of 160/110 mmHg. Which of the following might you find on further evaluation which would indicate that she has a specific named form of secondary hypertension.

A moon face appearance and optic atrophy

Microaneurysms on fundoscopy & Microalbuminurea on urine testing

Weak femoral pulses

A Renal bruit on abdominal auscultation

A diastolic murmur on auscultation over the aortic area.

STRETCH MARKS or STRIAE, as they are called in dermatology, are a form of scarring on the skin with an off-color hue. They are caused by tearing of the dermis, which over time may diminish, but will not disappear completely.
The GLUCOCORTICOID hormones responsible for the development of stretch marks affect the dermis by preventing the fibroblasts from forming collagen and elastin fibers, necessary to keep rapidly growing skin taut. This creates a lack of supportive material, as the skin is stretched and leads to dermal and epidermal tearing.

Cushing's disease refers to a pituitary-dependent cause of Cushing's syndrome: a tumor (adenoma) in the pituitary gland produces large amounts of ACTH, causing the adrenal glands to produce elevated levels of cortisol. It is the most common non-iatrogenic cause of Cushing's syndrome, responsible for 70% of cases excluding glucocorticoid related cases.
Other signs include polyuria (and accompanying polydipsia), persistent hypertension (due to cortisol's enhancement of epinephrine's vasoconstrictive effect) and insulin resistance (especially common in ectopic ACTH production), leading to hyperglycemia (high blood sugar) and insulin resistance which can lead to diabetes mellitus. Insulin resistance is accompanied by skin changes such as acanthosis nigricans in the axilla and around the neck, as well as skin tags in the axilla. Untreated Cushing's syndrome can lead to heart disease and increased mortality.

Explanation

STRETCH MARKS or STRIAE, as they are called in dermatology, are a form of scarring on the skin with an off-color hue. They are caused by tearing of the dermis, which over time may diminish, but will not disappear completely.
The GLUCOCORTICOID hormones responsible for the development of stretch marks affect the dermis by preventing the fibroblasts from forming collagen and elastin fibers, necessary to keep rapidly growing skin taut. This creates a lack of supportive material, as the skin is stretched and leads to dermal and epidermal tearing.

Cushing's disease refers to a pituitary-dependent cause of Cushing's syndrome: a tumor (adenoma) in the pituitary gland produces large amounts of ACTH, causing the adrenal glands to produce elevated levels of cortisol. It is the most common non-iatrogenic cause of Cushing's syndrome, responsible for 70% of cases excluding glucocorticoid related cases.
Other signs include polyuria (and accompanying polydipsia), persistent hypertension (due to cortisol's enhancement of epinephrine's vasoconstrictive effect) and insulin resistance (especially common in ectopic ACTH production), leading to hyperglycemia (high blood sugar) and insulin resistance which can lead to diabetes mellitus. Insulin resistance is accompanied by skin changes such as acanthosis nigricans in the axilla and around the neck, as well as skin tags in the axilla. Untreated Cushing's syndrome can lead to heart disease and increased mortality.

3. Your 55-year old Caucasian male patient comes to the office for a blood pressure check. You have noticed an increasing trend over the last several years. Three years ago his systolic blood pressure was 120 mmHg. Since that time he has gained weight (BMI 40) and has been under considerable stress from work and a recent divorce. Today his blood pressure is 140/90 which is consistent with two previous readings this year. He has no clinical symptoms except for occasional tension type headaches. Of the following choices, which are true?

He has not increased his cardiovascular risks due to the short time span
He has increased is cardiovascular risks by two fold
One would expect Kerley B lines on his chest x-ray
One would expect copper wiring on his eye exam
He has class 2 hypertension based on the JNC 7 guidelines

1, 4, 5

2, 4, 5

1, 3, 5

2, 4

http://upload.wikimedia.org/wikipedia/commons/thumb/5/5a/Kerley_b_lines.jpg/478px-Kerley_b_lines.jpg

Kerley lines are a sign seen on chest radiographs with interstitial pulmonary edema. They are thin linear pulmonary opacities caused by fluid or cellular infiltration into the interstitium of the lungs.

They are suggestive for the diagnosis of congestive heart failure, but are also seen in various non-cardiac conditions such as pulmonary fibrosis, interstitial deposition of heavy metal particles or carcinomatosis of the lung. Chronic Kerley B lines may be caused by fibrosis or hemosiderin deposition caused by recurrent pulmonary oedema.

Kerley B lines

These are short parallel lines at the lung periphery. These lines represent interlobular septa, which are usually less than 1 cm in length and parallel to one another at right angles to the pleura. They are located peripherally in contact with the pleura, but are generally absent along fissural surfaces. They may be seen in any zone but are most frequently observed at the lung bases at the costophrenic angles on the PA radiograph, and in the substernal region on lateral radiographs. Kerley B lines are seen in Congestive Heart Failure (CHF) and Interstitial Lung Diseases (ILD).

Explanation

http://upload.wikimedia.org/wikipedia/commons/thumb/5/5a/Kerley_b_lines.jpg/478px-Kerley_b_lines.jpg

Kerley lines are a sign seen on chest radiographs with interstitial pulmonary edema. They are thin linear pulmonary opacities caused by fluid or cellular infiltration into the interstitium of the lungs.

They are suggestive for the diagnosis of congestive heart failure, but are also seen in various non-cardiac conditions such as pulmonary fibrosis, interstitial deposition of heavy metal particles or carcinomatosis of the lung. Chronic Kerley B lines may be caused by fibrosis or hemosiderin deposition caused by recurrent pulmonary oedema.

Kerley B lines

These are short parallel lines at the lung periphery. These lines represent interlobular septa, which are usually less than 1 cm in length and parallel to one another at right angles to the pleura. They are located peripherally in contact with the pleura, but are generally absent along fissural surfaces. They may be seen in any zone but are most frequently observed at the lung bases at the costophrenic angles on the PA radiograph, and in the substernal region on lateral radiographs. Kerley B lines are seen in Congestive Heart Failure (CHF) and Interstitial Lung Diseases (ILD).

4. Which of the following microscopic changes can most likely be found in the kidneys of a patient with sudden and unexpected BP elevation to 210/160 mm Hg and bilateral papilledema?

Atherosclerotic plaques in the renal artery and its major branches

Circular hyaline deposits in the wall of arterioles and small arteries

Fibrinoid necrosis of the afferent and intraglomerular arterioles

Amyloid deposits in the vascular wall and interstitium

Fibrinoid necrosis
1. Necrotic damage to blood vessel wall
2. Leaking of proteins (including fibrin) into vessel wall results in bright pink
staining of the wall microscopically
3. Characteristic of malignant hypertension and vasculitis

Explanation

Fibrinoid necrosis
1. Necrotic damage to blood vessel wall
2. Leaking of proteins (including fibrin) into vessel wall results in bright pink
staining of the wall microscopically
3. Characteristic of malignant hypertension and vasculitis

5. A 42-year-old woman with chronic benign hypertension has an abdominal ultrasound that shows her left kidney is much smaller than the right one. What is the most likely etiology of her hypertension?

Renal artery stenosis due to fibromuscular dysplasia

Conn syndrome

Idiopathic (essential) hypertension

Renal artery stenosis due to atherosclerosis

Atherosclerosis is the predominant cause of renal artery stenosis in the majority of patients, usually those with a sudden onset of hypertension at age 50 or older.

Fibromuscular dysplasia is the predominant cause in young patients, usually females under 40 years of age. A variety of other causes exist. These include arteritis, renal artery aneurysm, extrinsic compression (e.g., neoplasms), neurofibromatosis, and fibrous bands.

Explanation

Atherosclerosis is the predominant cause of renal artery stenosis in the majority of patients, usually those with a sudden onset of hypertension at age 50 or older.

Fibromuscular dysplasia is the predominant cause in young patients, usually females under 40 years of age. A variety of other causes exist. These include arteritis, renal artery aneurysm, extrinsic compression (e.g., neoplasms), neurofibromatosis, and fibrous bands.

6. Hypertension affects the heart in each of the following ways except:

By causing concentric LVH

It increases to risk of arrhythmias especially for atrial fibrillation

It may dilate the aorta leading to aortic regurgitation

It produces pericardial damage and Pericarditis

It is an important cause of diastolic dysfunction & diastolic heart failure

Hypertension affects the heart in various ways, including causing concentric left ventricular hypertrophy (LVH), increasing the risk of arrhythmias such as atrial fibrillation, dilating the aorta leading to aortic regurgitation, and being an important cause of diastolic dysfunction and diastolic heart failure. However, it does not directly produce pericardial damage and pericarditis.

Explanation

Hypertension affects the heart in various ways, including causing concentric left ventricular hypertrophy (LVH), increasing the risk of arrhythmias such as atrial fibrillation, dilating the aorta leading to aortic regurgitation, and being an important cause of diastolic dysfunction and diastolic heart failure. However, it does not directly produce pericardial damage and pericarditis.

7. Miss Silverton is a 37-year-old female who presents with truncal obesity, purple striae on her abdomen and an elevated ACTH. Her blood pressure is 160/95. The most likely cause of her hypertension is:

Increased ACTH production by an adrenal tumor

Increased ACTH production because of adrenal hyperplasia

Increased ACTH production due to coarctation of the aorta

Increased pituitary ACTH production

Increased ACTH production due to renal artery stenosis

Conn’s syndrome

Use of hormonal contraceptives

Cushing's disease refers to a pituitary-dependent cause of Cushing's syndrome: a tumor (adenoma) in the pituitary gland produces large amounts of ACTH, causing the adrenal glands to produce elevated levels of cortisol. It is the most common non-iatrogenic cause of Cushing's syndrome, responsible for 70% of cases excluding glucocorticoid related cases.

Conn's syndrome is an aldosterone-producing adenoma.

Explanation

Cushing's disease refers to a pituitary-dependent cause of Cushing's syndrome: a tumor (adenoma) in the pituitary gland produces large amounts of ACTH, causing the adrenal glands to produce elevated levels of cortisol. It is the most common non-iatrogenic cause of Cushing's syndrome, responsible for 70% of cases excluding glucocorticoid related cases.

Conn's syndrome is an aldosterone-producing adenoma.