Uncontrolled hypertension in a Middle-Aged Male
Kulleni Gebreyes, MD
CHIEF COMPLAINT: Chest pain
HISTORY OF PRESENT ILLNESS:
A 49-year-old male comes to the emergency center at 1:00 a.m. complaining of chest pain which had started approximately two hours previously.
The patient stated that he had similar chest pains in the past, but never sought medical attention for them. The pain was reported in the precordium area, but it did not radiate to the left arm or to the jaw. The patient also complained of headache, which he had had off and on for the past several months. More often than not, the headache did no respond to over-the-counter analgesics.
, 百拇医药
The patient expressed anxiety about his health problem because he had been very healthy and very active in the past. He had never visited a physician until three years previously when he was in an automobile accident in which he sustained a fracture of the left leg. At that time his blood pressure was found to be elevated and he was referred to a primary care physician, who found evidence of mild congestive heart failure and placed him on an angiotensin converting enzyme (ACE) inhibitor and digitalis.
, 百拇医药
The patient stated that he had experienced decreased libido over the last few months, which he attributed to his medications. He has friends who have reported to him that they experienced decreased libido since starting on hypertension medications. The patient is concerned about early death or disability from his heart condition, but is reluctant to take the prescribed medication.
FAMILY AND SOCIAL HISTORY:
The patient is married and has three children of school age (12, 14, and 16 years old). He works as a security guard in a large plant on a rotating shift basis. His wife works as a clerk in a store. The patients father died of a myocardial infarction at the age of 62, and the mother, who is now 68 years old, is known to have hypertension and diabetes. The patient communicates more comfortably with his wife at the bedside. The patient does not smoke, reports no physical activity outside of his job, and consumes 2-4 beers on most weekdays, and 5-7 beers on weekends.
, http://www.100md.com
Questions
1. What else do you want to know?
2. What do you think is going on?
3. What do you want to do next?
PHYSICAL EXAMINATION
PHYSICAL EXAM:
General Appearance:The patient displays considerable anxiety and facial expressions of pain. He is alert and cooperative.
, 百拇医药
Vital Signs: His temperature, pulse and respiratory rate are normal, but his sitting blood pressure is 164/96. A repeat measurement taken 15 minutes later shows a blood pressure of 158/98. The patients weight is 190 lbs. and his height is 510.
HEENT:Pupils are equal round and reactive to light. No papilledema. Extraocular movements are intact.
Cardiovascular:Regular, rate and rhythm with positive S4. Two out of six systolic ejection murmur. Left wall heave. No jugular venous distension.
, 百拇医药
Respiratory: Clear to ascultation bilaterally. No wheezing, rales or rhonchi.
Abdomen: soft, non-tender, non-distended. Bowel sounds present.
Extremities: Minimal pedal edema. No cyanosis or clubbing.
Neurological: Awake and alert. Symmetric reflexes throughout.
Questions:
What tests do you want to order now?
, 百拇医药
In what order do you want to order these test?
What, if anything, do you want to do to start for treatment?
STUDIES AND LABORATORY TESTS:
Electrocardiogram: The following is the ECG obtained by the nurse.
LABORATORY: Routine blood chemistries were within the normal range.
Questions
What does the ECG show?
, 百拇医药
What is etiology (underlying cause) for the ECG changes?
What is the probable diagnosis?
What is a reasonable management plan?
ECG Interpretation
Frontal Plane Leads
There is a marked left axis deviation in the frontal plane. Notice that lead I is positive and AVF is negative. The amplitude of the QRS is very high in the frontal plane. Notice that on lead AVL (which is parallel to this patients QRS axis), the QRS amplitude is 2 millivolts, which exceeds the upper limit of normal of 1.5 millivolts.
, 百拇医药
Contrariwise, the axis of T is in the right axis quadrant. Notice that the T-wave on lead I is negative and AVF is slightly positive. This indicates a wide angle between QRS and T, thus suggesting marked left ventricular strain.
There is also a bifid P-wave, suggesting left atrial abnormality (P mitrale).
There is a J-point displacement reflected by S-T depression in the frontal plane leads in the leads that have a positive QRS complex. While this could be secondary to hypertrophy, it is very likely due to digitalis.
, 百拇医药
Horizontal Plane (precordial or V leads):
The precordial leads show negative QRS complexes with the exception of V-6. Notice the very high voltage of the QRS in most leads. This indicates that the axis of QRS is way to the back, again suggesting left ventricular hypertrophy, since the left ventricle is the posterior ventricle.
ECG INTERPRETATION:
Left ventricular hypertrophy, left atrial enlargement, and digitalis effect.
, 百拇医药
DIAGNOSIS AND MANAGEMENT PLAN
DIAGNOSIS:
The patient has uncontrolled hypertension with evidence of end organ damage.
MANAGEMENT:
Immediate plans are to reduce the blood pressure and perform serial ECGs cardiac enzyme tests. A head CT is required to rule out evidence of increased intracranial pressure. The patient needs a monitored bed on the ward for ruling out myocardial infarction and close monitoring of blood pressure. At this time, non-invasive blood pressure monitoring is appropriate. If the patients clinical status worsens, invasive blood pressure monitoring is indicated.
, http://www.100md.com
As with the treatment of acute coronary syndromes, patient also requires oxygen and intravenous access. Immediate blood pressure control may be obtained with nitroglycerin or a beta-blocker. Because of the history of mild congestive heart failure, ACE inhibitor is also a good drug of choice to improve cardiac output. There is no evidence of congestive heart failure at this time, and the patient does not need to continue taking digitalis.
The goal of long term management is to control the patients blood pressure to 140/90 mm Hg. The patient must be encouraged to take the ACE inhibitor regularly. In addition, an education plan must be developed to help the patient follow a low salt diet, increase physical activity, and reduce alcohol consumption.
, 百拇医药
Patient Education and Counseling Plan
1.Adherence to antihypertensive treatment: This topic is best addressed in a meeting between the patient and physician alone. The validity of the patients concern about impotence must be acknowledged, but it should be stressed that there can be causes of decreased libido other than antihypertensive medication. Not all antihypertensives affect sexual function, and the one prescribed to the patient is not known to cause impotence. The patient should be encouraged to try taking the ACE inhibitor as prescribed for a brief period (2-4 weeks) and report back to the physician any adverse effects. He should be reassured that there are other medications that can be prescribed to control blood pressure if the one he is on is not satisfactory.
, 百拇医药
2.Diet: Since the wife is responsible for preparing family meals, she should be invited to attend a dietary counseling session with her husband. They should also be given written educational materials on low-salt, low-fat diets.
3.Alcohol Consumption: The adverse effect of excessive alcohol intake on blood pressure and the patients risk of heart attack in view of his fathers medical history must be stressed. The patient should be asked to cut down to no more than 2 drinks per day.
, 百拇医药
4.Physical Activity: Physical activity counseling is likely to be most effective over a period of months or even years. The patient works in a relatively sedentary position, and if leisure time physical activity is not part if his lifestyle, he must first be made aware of the health benefits of exercise. Eventually he can be encouraged to begin walking 2-3 time per week, or exercising in his home. The patient is financially able to join a health club, and this can also be proposed to him to get him started with an exercise program., 百拇医药
CHIEF COMPLAINT: Chest pain
HISTORY OF PRESENT ILLNESS:
A 49-year-old male comes to the emergency center at 1:00 a.m. complaining of chest pain which had started approximately two hours previously.
The patient stated that he had similar chest pains in the past, but never sought medical attention for them. The pain was reported in the precordium area, but it did not radiate to the left arm or to the jaw. The patient also complained of headache, which he had had off and on for the past several months. More often than not, the headache did no respond to over-the-counter analgesics.
, 百拇医药
The patient expressed anxiety about his health problem because he had been very healthy and very active in the past. He had never visited a physician until three years previously when he was in an automobile accident in which he sustained a fracture of the left leg. At that time his blood pressure was found to be elevated and he was referred to a primary care physician, who found evidence of mild congestive heart failure and placed him on an angiotensin converting enzyme (ACE) inhibitor and digitalis.
, 百拇医药
The patient stated that he had experienced decreased libido over the last few months, which he attributed to his medications. He has friends who have reported to him that they experienced decreased libido since starting on hypertension medications. The patient is concerned about early death or disability from his heart condition, but is reluctant to take the prescribed medication.
FAMILY AND SOCIAL HISTORY:
The patient is married and has three children of school age (12, 14, and 16 years old). He works as a security guard in a large plant on a rotating shift basis. His wife works as a clerk in a store. The patients father died of a myocardial infarction at the age of 62, and the mother, who is now 68 years old, is known to have hypertension and diabetes. The patient communicates more comfortably with his wife at the bedside. The patient does not smoke, reports no physical activity outside of his job, and consumes 2-4 beers on most weekdays, and 5-7 beers on weekends.
, http://www.100md.com
Questions
1. What else do you want to know?
2. What do you think is going on?
3. What do you want to do next?
PHYSICAL EXAMINATION
PHYSICAL EXAM:
General Appearance:The patient displays considerable anxiety and facial expressions of pain. He is alert and cooperative.
, 百拇医药
Vital Signs: His temperature, pulse and respiratory rate are normal, but his sitting blood pressure is 164/96. A repeat measurement taken 15 minutes later shows a blood pressure of 158/98. The patients weight is 190 lbs. and his height is 510.
HEENT:Pupils are equal round and reactive to light. No papilledema. Extraocular movements are intact.
Cardiovascular:Regular, rate and rhythm with positive S4. Two out of six systolic ejection murmur. Left wall heave. No jugular venous distension.
, 百拇医药
Respiratory: Clear to ascultation bilaterally. No wheezing, rales or rhonchi.
Abdomen: soft, non-tender, non-distended. Bowel sounds present.
Extremities: Minimal pedal edema. No cyanosis or clubbing.
Neurological: Awake and alert. Symmetric reflexes throughout.
Questions:
What tests do you want to order now?
, 百拇医药
In what order do you want to order these test?
What, if anything, do you want to do to start for treatment?
STUDIES AND LABORATORY TESTS:
Electrocardiogram: The following is the ECG obtained by the nurse.
LABORATORY: Routine blood chemistries were within the normal range.
Questions
What does the ECG show?
, 百拇医药
What is etiology (underlying cause) for the ECG changes?
What is the probable diagnosis?
What is a reasonable management plan?
ECG Interpretation
Frontal Plane Leads
There is a marked left axis deviation in the frontal plane. Notice that lead I is positive and AVF is negative. The amplitude of the QRS is very high in the frontal plane. Notice that on lead AVL (which is parallel to this patients QRS axis), the QRS amplitude is 2 millivolts, which exceeds the upper limit of normal of 1.5 millivolts.
, 百拇医药
Contrariwise, the axis of T is in the right axis quadrant. Notice that the T-wave on lead I is negative and AVF is slightly positive. This indicates a wide angle between QRS and T, thus suggesting marked left ventricular strain.
There is also a bifid P-wave, suggesting left atrial abnormality (P mitrale).
There is a J-point displacement reflected by S-T depression in the frontal plane leads in the leads that have a positive QRS complex. While this could be secondary to hypertrophy, it is very likely due to digitalis.
, 百拇医药
Horizontal Plane (precordial or V leads):
The precordial leads show negative QRS complexes with the exception of V-6. Notice the very high voltage of the QRS in most leads. This indicates that the axis of QRS is way to the back, again suggesting left ventricular hypertrophy, since the left ventricle is the posterior ventricle.
ECG INTERPRETATION:
Left ventricular hypertrophy, left atrial enlargement, and digitalis effect.
, 百拇医药
DIAGNOSIS AND MANAGEMENT PLAN
DIAGNOSIS:
The patient has uncontrolled hypertension with evidence of end organ damage.
MANAGEMENT:
Immediate plans are to reduce the blood pressure and perform serial ECGs cardiac enzyme tests. A head CT is required to rule out evidence of increased intracranial pressure. The patient needs a monitored bed on the ward for ruling out myocardial infarction and close monitoring of blood pressure. At this time, non-invasive blood pressure monitoring is appropriate. If the patients clinical status worsens, invasive blood pressure monitoring is indicated.
, http://www.100md.com
As with the treatment of acute coronary syndromes, patient also requires oxygen and intravenous access. Immediate blood pressure control may be obtained with nitroglycerin or a beta-blocker. Because of the history of mild congestive heart failure, ACE inhibitor is also a good drug of choice to improve cardiac output. There is no evidence of congestive heart failure at this time, and the patient does not need to continue taking digitalis.
The goal of long term management is to control the patients blood pressure to 140/90 mm Hg. The patient must be encouraged to take the ACE inhibitor regularly. In addition, an education plan must be developed to help the patient follow a low salt diet, increase physical activity, and reduce alcohol consumption.
, 百拇医药
Patient Education and Counseling Plan
1.Adherence to antihypertensive treatment: This topic is best addressed in a meeting between the patient and physician alone. The validity of the patients concern about impotence must be acknowledged, but it should be stressed that there can be causes of decreased libido other than antihypertensive medication. Not all antihypertensives affect sexual function, and the one prescribed to the patient is not known to cause impotence. The patient should be encouraged to try taking the ACE inhibitor as prescribed for a brief period (2-4 weeks) and report back to the physician any adverse effects. He should be reassured that there are other medications that can be prescribed to control blood pressure if the one he is on is not satisfactory.
, 百拇医药
2.Diet: Since the wife is responsible for preparing family meals, she should be invited to attend a dietary counseling session with her husband. They should also be given written educational materials on low-salt, low-fat diets.
3.Alcohol Consumption: The adverse effect of excessive alcohol intake on blood pressure and the patients risk of heart attack in view of his fathers medical history must be stressed. The patient should be asked to cut down to no more than 2 drinks per day.
, 百拇医药
4.Physical Activity: Physical activity counseling is likely to be most effective over a period of months or even years. The patient works in a relatively sedentary position, and if leisure time physical activity is not part if his lifestyle, he must first be made aware of the health benefits of exercise. Eventually he can be encouraged to begin walking 2-3 time per week, or exercising in his home. The patient is financially able to join a health club, and this can also be proposed to him to get him started with an exercise program., 百拇医药