CASE Week1 (29/02/2012)

Case A General Check-Up

Case Objectives 1. Define the normal range of blood pressure in the adult population. 2. Understand the pathophysiology of hypertension and how it is defined and assessed in the human population. 3. Understand the role of hypertension in human morbidity and mortality. 4. Have an understanding of the major classes of drugs used to treat hypertension. 5. Recognise the important roles of diet and lifestyle in the development and management of hypertension.

Case Outline
Nathan Porter is a 25year old zoologist employed by the CSIRO, who has recently been offered the opportunity to participate in a 6-month Antarctic expedition. Today he presents to his GP for a preliminary medical assessment for the trip. Nathan is very keen to undertake the expedition he explains that he is excited about it but is worried about leaving his fiance for 6months. When asked about the relationship, Nathan states that it is going OK, except that when he is tired and stressed, he gets irritable and tends to argue with her. He admits that he is a worrier and has not been sleeping well. Nathan is anxious about the consultation. He has previously only attended the surgery for some travel vaccinations and minor respiratory conditions. He states that he worries about his own health as his own father died at the age of 54. His father died of a stroke he was overweight and was a heavy smoker. Nathan says that he used to play some sport at University, but since he graduated two years ago and moved in with his fiance, he has done little exercise and has gained about 10kg in weight. He rarely drinks alcohol on weekdays, but sometimes has a big night on the weekend. He takes no regular medications and has no known allergies. Nathan states that his 60yo mother suffers from diabetes but he doesnt know what kind of treatment she is on She doesnt have to give herself injections or anything. His paternal grandparents lived in the UK and both died as the result of heart attacks in their sixties. On examination, Nathan appears quite anxious. His blood pressure is 150/90. A repeat blood pressure taken after a 5minute rest is 145/95.

His heig is 183cm and he weighs 96kg . ght m w

On Exa amination n:
Mr Port appeare anxious. No anaem cyanosis or jaundi was det ter ed mia, ice tected. The thyroid e gland w not enla was arged. BP was 150 / 90, lying and standing. The same readings were record s w ded on bot arms. th Pulse w 100 and regular. No radio-fem was N moral delay was detec y cted. Carotiids were eq qual and had a n normal upstr roke and no bruits wer detected. o re Chest: The apex b beat was no displaced Heart sou ot d. unds were dual and the were no added d ere sounds. Chest e expansion w symmetrical on ins was spiration. Pe ercussion note was res sonant over all lung r fields. B Breath soun were ve nds esicular and there were no added sounds. d e Abdom men: There was no abd dominal dist tension. The abdomen was soft o palpation and no n on n organom megaly wa detected. The kidn as neys were not palpab and no renal brui were ble its identifie ed. Lower limbs: The peripheral pulses wer palpable. e re Eye exa amination: Fundoscop was norm : py mal. Urinaly ysis showed a trace of protein but no glucose d t e.

ECG: S Sinus rhythm No evid m. dence of lef ventricula hypertrop or axis deviation. Normal ft ar phy s ECG.

CBL Preparation (all students): o Define the following terms: Blood Pressure Systolic, Diastolic Hypertension Essential (Primary) Hypertension, Secondary Hypertension Fundoscopy Describe in general terms the methods used to diagnose hypertension. Calculate Nathans BMI. What is the ideal adult BMI range? What are the ranges for overweight / obese / underweight?

o o

Note: All students are expected to have prepared this material

Presentation Tasks (Student 1 and Student 2):

Present the case to your colleagues What other information would you like to obtain from Nathan? What investigations, if any, would you consider doing at this point? Present a problem list for Nathan

Student 1: What is a normal blood pressure range for a 25yo male? Does Nathan have hypertension? How might you confirm this? What groups of people are predisposed to developing hypertension? (Consider people with specific conditions as well as specific population groups) What is the relevance of hypertension if it is not causing any symptoms, why does it need to be managed / treated? Discuss the specific risks to target organs that occur in hypertensive patients.

Student 2: How does diet influence hypertension? What advice would you give to a patient regarding diet if they were mildly hypertensive? What other management strategies might you consider with respect to Nathans BP at this time? When would you consider putting him on an antihypertensive? Blood tests taken on Nathan showed a total cholesterol of 6.8mmol/L, a HDL of 1.1mmol/L and a fasting glucose of 5.3mmol/L. Using the Australian Cardiovascular Risk Charts, calculate Nathans risk and explain to Nathan (and your colleagues) exactly what this means. (For the purposes of this exercise, assume that Nathan is 45yo) Reference:

http://www.heartfoundation.org.au/SiteCollectionDocuments/A_Hypert_Guidelines20 08_2010Update_FINAL.pdf