(45 min)

Questions: 

1. Etiology and pathogenesis of hypertensive crises
2. Classification of crises
3. Complications of hypertensive crises
4. Diagnostic signs
5. Tactics and treatment of a patient with a crisis, depending on the presence or absence of complication                          

Clinical cases

1 case /   Patient A., 55 years old, appealed to the feldsher of the health center with complaints of headaches, mainly in the occipital region, flickering "flies" before the eyes and blurred vision , a feeling of noise in the ears.

From the anamnesis, it is known that the patient's mother suffers from hypertensive disease. Father died at the age of 54 from extensive myocardial infarction. The patient works as an economist. Smokes up a pack of cigarettes a day for 20 years. Headaches bother with 50 years, periodically there was an increase in blood pressure to 160/90 mm Hg.  Patient was not examined, on the advice of friends regularly took captopril. Deterioration in the last 2-3 months due to significant emotional overstrain.

Objectively: the state is satisfactory. The skin is usually moderate humidity. The patient is over-nutrition. There is no edema. Breathing rate = 20 per minute, vesicular breathing in the lungs, no wheezing. Percussion: the left border of the heart is located 1 cm outward from the midclavicular line. Heart sounds are clear, rhythmic, heart rate 112 beats / min., blood pressure 180/100 mm Hg. Abdomen palpation is soft, painless. Symptom tapping negative on both sides.

1. Formulate a presumptive diagnosis. Justify the answer.

2. What are the risk factors for the disease in this patient?

3. Define tactics in relation to the patient.

4. Name the methods of laboratory, instrumental diagnosis of this disease.

5. Make the algorithm of emergency care in the prehospital phase.

Case 2\ The doctor was called home to patient S., 55, who complains of pressure, burning pain in the chest, radiating to the left arm, under the left shoulder blade. The attack arose 1 hour ago. Reception of nitroglycerin did not give effect. The disease is associated with a stressful situation.

Objectively: the general state of moderate severity, clear mind, the body temperature is 36.8  C. The patient is restless, tossing about. The skin and visible mucous membranes are pale. Breathing rate = 22 per min. Vesicular breathing. Heart sounds are rhythmic, muffled. Heart rate 96 beats / min., Blood pressure  110/70 mm RT. Abdominal pathology was not detected. On the ECG, the ST interval is domed upward displaced, the T wave is fused with an ST interval.

Questions

1. Formulate a presumptive diagnosis. Justify.

2. Determine  management.

3. Additional methods to study this disease?

4. Create an algorithm for emergency care in the prehospital phase.

5. Give recommendations for secondary prevention.

Case 3/  Patient V., 42 years old, design engineer, was admitted to the therapeutic hospital in

emergency procedure (“ambulance”) with headache complaints, dizziness, flickering "flies" before the eyes, heartbeat, a feeling of inner trembling, nausea.

At the age of 35, when passing a medical commission for a patient for the first time revealed an increase in blood pressure (160/90 mm Hg. Art.). The state of health was good, to the doctor not аddressed. Over the last 3 years of the year, from time to time the headache began to disturb

pain in the temporal areas, dizziness, sleep disturbance. Blood pressure increased to 180/95 mm

Hg.

The appearance of this symptom he associated with emotional overload(he worked and studied at the same time). Irregularly used dibazol. In the summer period vacation well-being was good. Blood pressure at that time was normal.

On the day of the visit to the doctor, the patient had trouble at work, after which the above symptoms.

Objectively: the general condition of moderate severity, excited, face hyperemic, skin is wet. Height 172 cm, weight 94 kg. In the lungs vesicular breathing, no wheezing. Left ventricular push 1 cm outwards from the left mid-clavicular lines. The tones are quiet, the accent is II tone in the aortic zone, the rhythm is correct. Pulse intense 85 beats per minute. Blood pressure 180/100 mm Hg . The abdomen is soft, painless. Liver by Kurlov 9cm × 8cm × 7cm. Symptom of Pasternack is negative on both sides. There is no edema.

In the biochemical analysis of blood: total cholesterol 6.5 mmol / l

On ECG: the voltage is satisfactory, the electrical axis of the heart is horizontal, the rhythm

sinus, wave R в V5, V6 more than in V4.

1. Make a preliminary diagnosis.

2. Select a leading syndrome.

3. Determine the further tactics of management.

Case 4 

Patient P., 59 years old. Hypertensive heart disease  - within 5 years. For the last 3 months, she was taking atenolol at a dose of 25 mg x 2 times a day. Blood pressure  180/100 mm Hg,  Pulse - 48 beats / min. Concomitant diseases - type 2 diabetes mellitus. She does not smoke. The mother of the patient suffered a myocardial infarction at the age of 72 years.

Additional research methods.

Common blood test: without pathology. Urin analysis - protein 0,033, sugar - abs, leukocytes 0-1 in p / sp. Biochemical analysis of blood: potassium 3.5 mmol / l, blood glucose - 5.1 mmol / l, creatinine 116 μmol / l, total cholesterol - 7.1 μmol / l

EchoCG: hypokinesis of the posterior wall of the left ventricle, LVMI - 175 g / m2 (the norm for women is up to 110 g / m2), the thickness of the intima-media complex of the carotid arteries is 1.2 cm (the norm is before 0.9 cm). Microalbuminuria in the analysis of urine - 120 mg / day. (the norm is 30-300 mg / day.).

Questions:

1) What is the stage of hypertension?

2) What are additional risk factors for a patient?

3) What organs of targets are affected?

4) What is the risk of developing complications?

5) diagnosis?

6). What antihypertensive drugs will be prescribed for the treatment of hypertension?

Case 5 

A 68-year-old female patient hospitalized for coronary artery disease, progressive angina pectoris suddenly developed chest pain, an intense headache (mainly in the occipital region), single vomiting without prior nausea and subsequent relief, difficulty breathing, coughing. When coughing, a frothy pink sputum is secreted. History of arterial hypertension (optimal blood pressure  145/95 mm Hg). Objectively: the state is severe. The patient is inhibited, the position of orthopnea. The skin is pale, covered with cold sweat, pronounced cyanosis. The breathing is rapid, fluttering, with the participation of auxiliary muscles. Respiratory rate =  28 in 1 min. Blood pressure 195/110 mm Hg art., pulse - 96 in 1 min. Muffled heart sounds, tachycardia. Auscultation over the entire surface of the lungs plentiful mixed caliber moist rales are heard (mostly medium and large bubble).

1. What is your diagnosis?

2. Your tactics?

Case 6

A 20-year-old student, who considers herself generally healthy, in the past has noted a moderate increase in blood pressure. Blood pressure on the forearm 160/90 mm Hg, on the thigh 120/60 mm Hg.

1.       Management.

2.       Diagnosis.

Case 7

37-year-old woman with a blood pressure of 160/90 mmHg, In the analysis of urine - protein 1.5 g / l, erythrocytes - 10 -12 in the field of view.

 Diagnosis.

Management and treatment.