Surgical Hypertension (Pestana) Flashcards
A 45 year old lady comes to your office for a “regular checkup”. On repeated determinations you confirm the fact that she is hypertensive. When she was in your office three years ago, her blood pressure was normal. Laboratory studies at this time show a serum sodium of 144 mEq/L, a serum bicarbonate of 28 mEq/L, and a serum potassium concentration of 2.1 mEq/L. The lady is taking no medications of any kind.
What is it? - Hyperaldosteronism. Possibly adenoma.
How is the diagnosis made? - Start with determinations of aldosterone and renin levels. If confirmatory (aldo high, renin low) proceed with determinations lying down and sitting up, to differentiate hyperplasia (not surgical) from adenoma (surgical). Treat the first with aldactone. Pursue the second with imaging studies (CT scan or MRI) and surgery.
A thin, hyperactive 38 year old lady is frustrated by the inability of her physicians to help her. She has episodes of severe pounding headache, with palpitations, profuse perspiration and pallor, but by the time she gets to her doctor’s office she checks out normal in every respect.
What is it? – Suspect pheochromocytoma.
How to diagnose it? - Start with 24 hr. urinary determination of metanephrine and VMA (Vanillylmandelic acid). Follow with CT scan of adrenal glands. Surgery will eventually be done, with careful pharmacological preparation with alpha-blockers.
A 17 year old man is found t have a blood pressure of 190/115. This is checked repeatedly in both arms and it is always found to be elevated, but when checked in the legs it is found to be normal.
What is it? - Coarctation of the aorta.
Further testing; start with a chest X-Ray, looking for scalloping of the ribs. Eventually aortogram and ultimately surgery.
A 23 year old lady has had severe hypertension for two years, and she does not respond well to the usual medical treatment for that condition. A bruit can be faintly heard over her upper abdomen.
What is it? - Renovascular hypertension due to fibromuscular dysplasia.
Management: I hope they only ask you to identify this one in an extended matching set. How to proceed with the diagnosis is a can of worms. There are a million tests, mostly invasive and expensive, and none with clear-cut reliability. Eventually arteriogram will precede surgical correction (or balloon dilatation).
A 72 year old man with multiple manifestations of arteriosclerotic occlusive disease has hypertension of relatively recent onset, and refractory to the usual medical therapy. He has a fain bruit over the upper abdomen.
What is it? - Renovascular hypertension due to arteriosclerotic plaque at the origin of the renal artery…or arteries (this is usually bilateral). I hope you are not asked to manage it. To the problems outline above, add the difficult, equation of guessing which manifestation of his arteriosclerotic disease is going to kill him first.
