Case of the week - Week 2

Question 1

What examinations are recommended by NICE for those with a diagnosis of hypertension?

Answer 1

Urine albumin:creatinine ratio for proteinuria and a dipstick test for microscopic haematuria

Question 2

What is meant by proteinuria?

Answer 2

Protein in the urine

Question 3

What is meant by haematuria?

Answer 3

Blood in the urine

Question 4

What drug would you recommend to a 48 year old white male with no presence of type II Diabetes Mellitus?

Answer 4

An ACE inhibitor such as lisinopril

Question 5

What is a normal total cholesterol level?

Answer 5

<5mmol/L

Question 6

What is a normal HDL-C level?

Answer 6

> 1mmol/L

Question 7

Why is HDL good and LDL bad?

Answer 7

LDL can build up in the blood vessel walls and can lead to atherosclerosis and thus risk of MI or stroke
HDL absorbs excess cholesterol in the blood and carries it back to the liver to be removed from the body, reducing the risk of atherosclerosis

Question 8

What ASSIGN score would suggest an increased Cardiovascular risk?

Answer 8

> 20

Question 9

What are the limitations of cardiovascular risk scoring tools?

Answer 9

It does not take into consideration other risk factors such as ethnicity, BMI, physical inactivity and so should be used alongside clinical examination

Question 10

Why is the patient told to avoid grapefruit when he is prescribed statins?

Answer 10

Grapefruits contain a furanocoumarin
This inactivate Cytochrome P450 3A4 which usually metabolises statins, so statins aren’t metabolised and so the amount in the blood increases
This makes side effects more likely

Question 11

Why does Mr Smith present with a dry cough after 6 weeks of taking lisinopril?

Answer 11

ACE inhibitors cause the breakdown of bradykinin and substance P
The products of this can accumulate in the lower respiratory tract and thus can cause a dry cough

Question 12

What are some side effects of ACE inhibitors?

Answer 12

Dry cough
Renal dysfunction
Angioneurotic oedema
Hyperkalaemia
Headaches
Fatigue
Hypotension

Question 13

What alteration would you make to his treatment, after the dry cough has developed?

Answer 13

Offer an ARB such as losartan or irbesartan

Question 14

His blood pressure remains uncontrolled after standard medication, what would you do next?

Answer 14

Provide a mineralocorticoid antagonist such as spironolactone or epelerone