история Hypertensive disease with predominant damage. hearts without (congestive) heart failure

General information
Name of the patient: Любовь Николаевна
Age: 71 years old
Gender : Female
Current position: retired
Date of admission to the clinic:17-04-2024
Clinical diagnosis:Hypertensive disease with predominant damage. hearts
without (congestive) heart failure
Patient's complaints
Main complaints
04/03/24 10-50 h Examination by doctor Chudinovskikh T.I. together with
the manager dept. Malchikova S.V.
Complaints of headaches, dizziness, noise in the head, nausea, general
weakness, malaise with increased blood pressure.
- periodic interruptions in the functioning of the heart, palpitations, general
weakness, sweating, periodic feeling of shortness of breath
-shortness of breath with slight physical exertion (when climbing floors,
walking at a distance of up to 50-100m)
- periodic pain of a compressive nature behind the sternum, often
associated with physical activity, with irradiation to the left arm
- occasional heartburn
ANAMNESIS MORBI.
Has suffered from high blood pressure since the age of 60 (maximum blood
pressure 210/110, normal blood pressure 120/70 mmHg).
For AMB cards since 2017 - IBS, CAG, load tests were not carried out
Constantly takes medications: previously took rosuvastatin (Roxera),
currently does not take it, bisoprolol (Concor) 5 mg in the morning,
amlodipine + valsartan (Vamloset) 5/80 mg twice a day, previously took it
once a day, currently 2 times a day for 10 days, also currently taking:
calcium DZ-Nycomed 1 tablet 2-3 times a day, rabeprazole (Nexium) 20 mg
in the morning, Cetrin 10 mg in the morning, Magnerot 1 tablet/day
She noticed a deterioration in her health within 1 month, when she noted
unstable blood pressure (up to 210/100), complaints of headaches,
dizziness, noise in the head, nausea, general weakness, malaise with
increased blood pressure, periodic interruptions in heart function,
palpitations, general weakness, sweating, periodic feeling of lack of air,
shortness of breath with slight physical exertion (when climbing floors,
walking at a distance of 50-100 m), periodic pain of a compressive nature
behind the sternum, more often associated with physical activity, radiating
to the left arm. I couldn’t make an appointment for M/F. I contacted a
doctor at the KSMU clinic. Sent to the KSMU clinic for selection of therapy
and examination.
ANAMNESIS VITAE.
Concomitant diseases: Ovarian cancer T2NOM0 stage II, surgical treatment
- laparotomy in 1993 (extirpation of the uterus with appendages) AChT 7
courses III class gr (1.06.23 oncologist, CT OGK dated 12.01.23 - CT picture
of interstitial changes in the lungs, may correspond to fibrous changes
(idiopathic pulmonary fibrosis?), signs of COPD, atherosclerosis of the
aorta and coronary arteries, single focal changes in the vertebrae, signs of
extraorgan formation of the bronchial cavity, CT OGK from 7.03.23
interstitial changes in the middle lobe of the right lung, lingular segments
and the lower lobe of the left lung (probably as part of post-inflammatory
changes), lymphadenopathy was not detected, nodular formations in the
bed of the removed spleen, paracolytically on the left, along the liver
capsule in the S5 projection, FGDS from 6.03.23 gastritis, DGR, VCS from
6.03.23 did not pass, OSG from 02.21.23- Convincing scintigraphic signs of
focal lesions of the skeletal system of a secondary (mts) nature were not
revealed in this study, degenerative-dystrophic changes in the spine, joints,
CA 125-3.1, MRI OBP from 03/25/23 - cyst of the general gallbladder,
steatosis of the pancreas, polysplenia, simple renal cysts , Ultrasound OBP,
OMT from 04/21/23 - differential changes in the liver, pancreas, condition
after cholecystectomy, accessory spleen, condition after extirpation of the
uterus with appendages, MRI OMT from
05/30/23 - condition after extirpation of the uterus with appendages, MRI
data for pregnancy were not detected
Bronchial asthma of mixed origin, persistent, moderate to severe,
controlled, remission Bilateral pneumofibrosis, pulmonary calcifications,
focal pneumofibrosis 5 on the right. DN 0 (pulmonologist dated 01/12/23,
recommended: ing vilanterol/fluticasone furoate (ellipta) 22/184 mcg 1 time
per day, fenoterol/ipratropium bromide 1-2 times as needed, currently does
not use inhalers)
Postoperative hypothyroidism, hypoparathyroidism, drug compensation,
regularly takes alfacalcidol (alfadol) 0.25 mcg 4 tablets in the morning,
levothyroxine (L-thyroxine) 75 mcg/day, endocrinologist GERD without
esophagitis. PHES (cholecystectomy in 2017 for cholelithiasis),
gastroenterologist dated 03/29/23,
FGDS from 2018: reflux esophagitis, NK stage 1, recommended: Nexium 20
mg, 1 tablet 1 row, mebeverine
200 mg 1 caps twice a day for 4 weeks, paccreatinine 10,000 units three
times a day for 4 weeks, then as needed
2 (further
There were no injuries. Operations: removal of the spleen due to a rupture
during an accident, revision of the spleen cavity,
birth,
thyroidectomy, EM with appendages, cholecystectomy from 2017 for
cholelithiasis, appendectomy,
Opisthorchiasis (+)
Gastric resection for gastric ulcer. Denies tuberculosis, sexually
transmitted diseases, hepatitis A.
hovoy nome oyanie moeg
Allergy history: vit gr B, penicillin, iodine-containing angioedema. Blood
transfusions in
ico-profile
Menopause since 1993, 6-9, r-6, m/a-3, 6/0
no medical history. Heredity: mother's ovaries were folded. Doesn't abuse
alcohol. I do not smoke.
Itsinsky mustache
available
Consultation with an ophthalmologist (stage 1 retinal angiopathy) from
11.2023, gynecologist from 11.2023, atrophic vaginitis, menopause since
50 years, FLG from 03.20.24 without pathology
knowledge of Opera to eat ms
Epid. medical history: for the last 2 weeks I have not been in contact with
infectious patients, I have not traveled abroad
/GIM should
traveled, denies contact with persons returning from abroad, denies fever
within 2 weeks, was ill with Covid in August 2022, not vaccinated
STATUS PRASESENS
General condition is satisfactory. Consciousness is clear. Position active.
Body temperature 36.6 C Correct physique. The skin is clean, physiological
in color. Turgor is preserved. Subcutaneous fat tissue is overdeveloped.
Peripheral lymph nodes are not enlarged.
The thyroid gland is heterogeneous and painless on palpation. The joints
are not changed. The chest is of the correct shape. Both halves of it
equally participate in the act of breathing. Percussion above the lungs is a
clear pulmonary sound. There is hard breathing in the lungs, wheezing
cannot be heard. Respiratory rate 17/min. Borders of the heart: left - along
the left midclavicular line, right - the right edge of the sternum, upper - the
third rib. Heart sounds are clear, the rhythm is correct. No noises are heard.
organization of the territory: their reception was kept secret.
130/80 mmHg Blood pressure in the left arm is 130/80 mm Hg. Pulse 64 per
minute, rhythmic, normal filling and tension. The pulsation in the peripheral
arteries of the extremities is preserved and symmetrical. On auscultation,
no sounds are heard over the renal and carotid arteries. The tongue is
clean and moist. Zev is clean. The tonsils are normal.
The abdomen is of normal shape, soft, painless on palpation. Muscle
protection is not expressed.
The liver is not enlarged and painless. Dimensions according to Kurlov: 9 x
8 x 7 cm. The spleen is not palpable.
The kidneys are not palpable, their area is painless. Pasternatsky's
symptom is negative on both sides. The stool is not disturbed. Urination is
normal. Pastyness of the feet and legs. BMI 34.5 FROM 93
DIAGNOSIS:
Hypertension III? stage, uncontrolled, risk group 4 (very high). ?, target
blood pressure less than 140/80 mmHg
IHD. Angina pectoris? LDC? PBPNPG
HFpEF? stage 2 A?. FC 3.
Obesity of the 1st degree of the abdominal type. Hypercholesterolemia.
Ovarian cancer T2NOMO stage II, surgical treatment - laparotomy in 1993
(extirpation of the uterus with appendages) AChT 7 courses III class group
Bronchial asthma of mixed origin, persistent, moderate to severe,
controlled, remission Bilateral pulmonary fibrosis, pulmonary calcifications,
focal pulmonary fibrosis S5 on the right. DN O Postoperative
hypothyroidism, hypoparathyroidism, drug compensation
GERD without esophagitis. PHES
Main diagnosis
Hypertensive [hypertensive] disease with predominant damage to the heart
without (congestive) heart failure
Topographic percussion.
Upper borders of the lungs
Top standing height
Width of Kroenig
margins
Right lung
4 cm
5 cm
Left lung
4 cm
5 cm
Lower borders of the lungs
Lines
Parasternal
Midclavicular
Anterior axillary
Midaxillary
Posterior axillary
Scapular
Paravertebral
On right
5th intercostal space
6th intercostal space
7th intercostal space
8th intercostal space
Could not determine
Left
7th intercostal space
8th intercostal space
Mobility of the lower pulmonary border
Lines
Midclavicular
Midaxillary
Scapular
On right
Could not determine
Left
On auscultation, vesicular breathing occurs over the entire surface
of the lungs. Adverse respiratory sounds: dry wheezing in the area of the
apex of the lungs. Bronchophony is not changed.
Examination of the circulatory organs
There are no deformations or deformations in the heart area.
Pulsation in the region of the heart: the apex beat is not visually detected,
there is no systolic retraction in the area of the apex beat, there is no
pulsation in the 2nd and 4th intercostal spaces on the left. Not detected:
pulsation in the extracardiac area: “carotid dance”, pulsation of the jugular
veins in the jugular fossa, epigastric pulsation. The apical impulse is
palpated in the 5th intercostal space, 1 cm outward from the left
midclavicular line, intensified, high, 2 cm wide. The symptom of “cat
purring” is negative.
The pulse is asymmetrical in both hands, irregular, regular,
frequency 61 beats per minute in the right hand, weak filling and tension.
Limits of relative cardiac dullness
Right - 1.5 cm outward from the right edge of the sternum at the
level of the 4th intercostal space;
Left - 1.5 cm outward from the left midclavicular line in the 5th
intercostal space;
Upper - 3rd intercostal space along the left parasternal line.
Limits of absolute cardiac dullness
Right - along the left edge of the sternum in the 4th intercostal space;
Left - at the level of the mid-clavicular line in the 5th intercostal
space;
Upper - along the left parasternal line in the 4th intercostal space.
The length of the heart according to Kurlov is 15 cm;
The diameter of the heart according to Kurlov is 13 cm.
The width of the vascular bundle is 5 cm. The configuration of the
heart is aortic.
Auscultation of the heart and large vessels:
The rhythm is irregular, two-part, heart sounds are weak and muffled.
There is an accent of 2 tones over the aorta. The timbre is not changed.
Heart rate 61 per minute. Bifurcations and splitting, additional tones are
not detected. Intracardiac murmurs are not detected. Extracardiac
murmurs: pericardial friction murmur and pleuropericardial friction murmur
are not heard. Vascular murmurs: spinning top murmur, double VinogradovDurazier murmur, murmurs over the abdominal aorta and renal vessels are
not detected.
Arterial pressure
Right arm 160/90 mmHg.
Left arm 160/90 mmHg.
Examination of the digestive organs
The abdomen is round in shape, symmetrical, the anterior abdominal
wall is involved in the act of breathing. There are no visible peristaltic or
antiperistaltic movements. The abdominal circumference at the level of the
navel is 107 cm. The development of subcutaneous venous anastomoses
has not been detected. On superficial palpation, the abdomen is painful in
the left flank and umbilical region. Local and general tension of the
abdominal wall and tumor formations are not detected. A hernial protrusion
in the peri-umbilical region with a diameter of up to 6 cm is determined by
palpation. The Shchetkin-Blumberg symptom is negative. It was not
possible to perform deep palpation of the abdomen due to severe
abdominal pain. On palpation, the liver is located 1 cm below the edge of
the right costal arch. The edge of the liver is soft, rounded, the surface is
smooth, palpation is painless. The gallbladder is not palpable. Symptoms of
Courvoisier, phrenicus phenomenon, Obraztsov-Murphy are negative. The
spleen is not palpable. When percussing over the entire surface of the
abdomen, a tympanic sound is detected. Mendel's sign is negative. The
dimensions of the liver according to Kurlov are 11*10*8 cm. Symptoms of
Ortner, Vasilenko, Zakharyin are negative. Dimensions of the spleen
according to Kurlov: diameter 7 cm, length 9 cm. When auscultating the
abdomen, increased intestinal motility and rumbling are heard. Peritoneal
friction sounds and vascular sounds are not heard. The stool is unformed,
liquid, up to 8 times a day, alternating with constipation. Defecation is
painless and spontaneous.
Examination of the urinary organs
The skin in the lumbar region is pale pink. No redness or swelling of
the skin is detected. Swelling of the tissues is noted. The suprapubic
region is not changed. The kidneys and bladder are not palpable. The
effleurage symptom is negative on both sides. The bladder is 4 cm below
the navel. The percussion sound above the pubis is tympanic. Urination is
painless, up to 5-6 times a day. Diuresis 1000-1500 ml/day.
Study of the nervous system.
Consciousness is clear. Memory for real events is reduced. Insomnia
associated with nightmares and inability to sleep. There are no speech
disorders. Coordination of movements is normal. Reflexes are preserved.
Convulsions and paralysis are not observed. Hearing is reduced.
Dermographism is white, quickly disappearing.
Study of the endocrine system.
The neck in the area of the thyroid gland is swollen and edematous.
The thyroid gland is not palpable and painless. The shape of the palpebral
fissures is normal, there is no bulging eyes.
Preliminary diagnosis and its rationale
Based on the patient's complaints of sudden rises in blood pressure
to 260/100 mmHg, working pressure 160/90 mmHg, headache, dizziness,
shortness of breath, a feeling of heaviness and fullness in the left half of
the chest, pain and a burning sensation in the heart area with irradiation
under the left shoulder blade, numbness of the left arm and leg, a feeling of
interruptions in the heart, visual hallucinations, weakness, a feeling of fear,
it can be assumed that the cardiovascular system is affected.
The following syndromes have been identified:
arterial hypertension syndrome based on the patient’s complaints of
periodic headaches that occur with excitement, physical activity, and
increased blood pressure, which can be relieved by taking Enap at rest. For
visual impairment in the form of visual hallucinations and nightmares and
objective data - weak pulse, weak filling, accent of 2 tones over the aorta.
There is an increase in blood pressure to 240-270/100-140 mmHg. with
excitement, physical activity, at rest.
left ventricular hypertrophy syndrome based on objective data:
displacement of the apical impulse to the left, strengthening of the apex
impulse, expansion of the boundaries of relative cardiac dullness to the left,
aortic configuration of cardiac dullness.
pain syndrome based on complaints of pain and a burning sensation
in the chest during attacks of high blood pressure or the influence of minor
physical activity.
cardiac arrhythmia syndrome based on the patient’s complaints of a
feeling of interruptions in the heart’s function, a feeling of “fading” of the
heart and based on an objective examination - the pulse is asymmetrical in
the radial arteries of the right and left arms, non-rhythmic.
chronic heart failure syndrome based on complaints of decreased
performance, fatigue, palpitations and shortness of breath with minor
physical exertion, and the absence of symptoms at rest.
The preliminary main diagnosis is hypertension:
- presence of risk factors: age over 65 years, abdominal obesity,
family history of hypertension.
- the absence of clinical changes in the organs involved in the
regulation of blood pressure: kidneys, endocrine glands allows us to
exclude secondary arterial hypertension.
lability of blood pressure during the day.
Hypertensive crises associated with psycho-emotional stress,
physical activity and at rest are noted.
Since there are changes in target organs caused by arterial
hypertension - left ventricular hypertrophy, we assume stage 3. Blood
pressure increased to 270/140 mmHg. - 3rd degree. A high-risk group, as
there is left ventricular hypertrophy, but no associated diseases have been
identified.
From the medical history, it was revealed that the last deterioration
occurred on 04/01/14 against the background of complete rest and was
accompanied by headache, dizziness, pain in the left half of the chest,
radiating under the left shoulder blade, numbness of the left arm and leg,
and an increase in blood pressure to 260/100 mm. Hg It follows from this
that the patient experienced a hypertensive crisis. The crisis developed
suddenly, developed quickly, was manifested by a headache, a feeling of
fear and lack of air, therefore this is type 1 of a hypertensive crisis. No
complications were noted, so the crisis was uncomplicated.
Complications of the underlying disease - atrial fibrillation, a
permanent form: the patient complains of a feeling of interruptions in the
work of the heart, a feeling of “fading” of the heart, objectively the pulse in
the extremities is asymmetrical, arrhythmic.
Chronic heart failure FC IIb : moderate limitation of physical activity.
The patient feels normal at rest, but when performing more significant
physical activity, palpitations, shortness of breath, weakness and the
appearance of anginal pain appear.
Based on the patient’s complaints, life history, medical history, and
objective data, a preliminary diagnosis can be made:
Main: Hypertension grade 3, stage 3, risk 4 (very high risk group abdominal obesity, left ventricular hypertrophy). Hypertensive crisis from
04/02/14, type 1, uncomplicated.
Complication of the underlying disease: atrial fibrillation, permanent
form. CHF IIb FC.
. Plan for additional research methods
Laboratory methods:
1. Complete blood count - exclusion of secondary arterial
hypertension, signs of which may be: anemia, erythrocytosis, leukocytosis,
accelerated ESR.
The analysis may show an increase in the content of red blood cells,
hemoglobin and hematocrit (“hypertensive polycythemia”).
. A general urine test is used to rule out damage to the kidneys, as a
target organ for hypertension.
In the analysis, microalbuminuria (40-300 mg/day) and glomerular
hyperfiltration (normally 80-130 ml/min) are possible, which indicate the
second stage of the disease.
. Zimnitsky's test.
With the development of hypertensive nephropathy, hypo- and
isosthenuria are possible.
. Biochemical blood test - glucose, cholesterol, potassium, creatinine
to assess risk factors and exclude secondary hypertension. Determination
of the level of cholesterol, LDL, VLDL and HDL, triglycerides, phospholipids
- to determine atherosclerotic vascular damage. CRP, fibrinogen presence/absence of an inflammatory process.
The analysis expects hyperlipoproteinemia (in the presence of
atherosclerosis), increased cholesterol, LDL, TG; increased levels of
creatinin and urea (with the development of kidney pathology).
. Determination of thyroid hormones - exclusion of hyperthyroidism,
secondary hypertension, exclusion of damage to the thyroid gland as a
target organ for hypertension.
The analysis may increase or decrease TSH, T3 and T4 (with
thyrotoxicosis and hypothyroidism, respectively).
Instrumental methods:
1.
ECG - diagnosis of hypertrophy of the heart.
)
Width of tooth PII > 0.11 s;
)
Predominance of the negative phase of the P wave ( V 1) with
a depth of > 1 mm and a duration of > 0.04 s.
. Echo-CG - for diagnosing left ventricular hypertrophy, assessing
myocardial contractility, identifying valvular defects as a cause of
hypertension.
) thickness of the LVAD > 1.2 cm;
) thickness of the bladder > 0.2 cm;
) m > 200 g - high myocardial hypertrophy.
. 24-hour Holter monitoring to monitor blood pressure dynamics and
parallel diagnosis of myocardial condition.
. Ultrasound of the carotid arteries, kidneys, adrenal glands, thyroid
gland - to exclude damage to these organs or as target organs in
hypertension.
. Examination of the fundus to identify damage to the organ of vision
as an associated condition with hypertension.
Possible changes in the fundus: narrowing of arterioles, variability in
their caliber, hemorrhages, retinal edema, symptoms of “copper” or “silver”
wire.
. Ultrasound of the abdominal organs - to exclude damage to the liver
and portal vein, as well as to determine free fluid in the abdominal cavity.
. Results of additional research methods
General blood test dated 04/01/14
red blood cells
Hb
CPU
leukocytes
PO Box
s/y
lymphocytes
monocytes
ESR
norm
3.9 - 5.0 * 1012g/l
125 - 140
28 - 33 pg
3.0 - 9.0 * 109 g/l
13
63
23
6
2 - 10 mm/h
index
3.7*1012
108
29 pg
6.1*109
3
65
25
7
15
Biochemical blood test dated 04/01/14
glucose
AST
KFC
norm
6.8 mmol/l
32.4 units/l
19.4 IU
index
3.3 - 6.1
0 - 31
10 - 110
General urine test dated 04/01/14
color
transparency
Specific gravity
norm
Straw yellow
transparent
1012-1016
index
Straw yellow
Transparent
-
protein
leukocytes
Erythrocytes of St.
Epithelium is flat
- 3 in p/z
0-1-2
0 - 3 in p/z
1.0
0 - 1 in p/z
12
2 - 4 in p/z
Survey X-ray of the chest organs dated 04/01/14
Conclusion: on a plain X-ray of the chest organs: the lung tissue is of
satisfactory transparency. The roots are structural. The aperture is clear.
The sinuses are free. The heart is enlarged in diameter to the left. The
aorta is calcified.
Biochemical blood test dated 04/02/14
AST
ALT
Total protein
Albumen
Total cholesterol
HDL cholesterol
TG
Glucose
Potassium
Sodium
urea
creatinine
norm
0 - 31
0 - 32
66 - 87
35 - 50
3.2 - 5.7
1.16 - 1.68
0.15 - 1.71
3.3 - 6.1
3.6 - 5.5
136 - 145
1.7 - 8.3
44 - 98
index
15.8 units/l
14.7 units/l
68.6 g/l
35.6 g/l
6.33 mmol/l
0.8 mmol/l
2.78 mmol/l
5.56 mmol/l
4.39 mmol/l
140 mmol/l
9.8 mmol/l
109 µmol/l
Biochemical blood test dated 04/02/14
index
6.33 mmol/l
0.8 mmol/l
2.78 mmol/l
1.28 mmol/l
4.25 mmol/l
6.91 mmol/l
Total cholesterol
Alpha cholesterol
TG
Pre -B PP
runway
CA
Biochemical blood test dated 04/02/14
TSH
T4
T3
norm
0.17 - 4.05
60 - 160
1.2 - 2.8
index
3.54 mIU/l
78.98 nmol/l
1.51 nmol/l
Serological study
Bordet-Wassermann reaction
Zacks reaction
Negative
Negative
General urine test dated 04/02/14
color
transparency
Specific gravity
protein
leukocytes
Epithelium is flat
slime
norm
Straw yellow
transparent
1012-1016
- 3 in p/z
0 - 3 in p/z
-
index
Straw yellow
Transparent
1012
4 - 6 in p/z
4 - 6 in p/z
+
Coagulogram from 04/02/14
Fibrinogen
APTV
Thrombin time
GAT
HZF
INR
RFMK
norm
2 - 4%
28 - 40''
14 - 17''
10 - 15''
4 - 10'
0.89 - 1.2
3.38 - 4.0 mg/100ml
index
4.95%
thirty''
17''
12''
15'
1.01
5.0 mg/100ml
Biochemical blood test dated 04/07/14
Potassium
Urea
Creatinine
norm
3.6 - 5.5
1.7 - 8.3
11 - 98
index
4.15 mmol/l
17.3 mmol/l
293 µmol/l
General urine test dated 04/07/14
color
transparency
Specific gravity
protein
leukocytes
Epithelium is flat
Hyaline granular
cylinders
fungus
norm
Straw yellow
transparent
1012-1016
- 3 in p/z
0 - 3 in p/z
0-1
index
Straw yellow
Transparent
0.2
70 - 80 in p/z
A lot
0-1
-
+
Urinalysis according to Nechiporenko 3 from 04/07/14
Leukocytes
red blood cells
cylinders
30,000
4750 St.
No
Urinalysis according to Nechiporenko 5 from 04/07/14
leukocytes
red blood cells
cylinders
Epithelium is flat
Mycelium and spores
bacteria
150,000
4250 St.
No
A lot
++
++
ECG from 04/02/14
Conclusion: atrial fibrillation. Heart rate 60/min. Ventricular
extrasystole. Enlargement of the left ventricle with slight overload.
Cicatricial changes in the anteroseptal region and anterolateral wall.
Echo-KG from 04/03/14
Left ventricle: ESR 3.4 cm, ESR 5.3 cm, ESR 47 ml. KDO 133 ml. UO
86 ml. PV 65%. FU 36%. MZHD. 12-13 mm. Rear wall 12-13 mm.
Left atrium: 5.0x6.7x5.1 cm.
Right ventricle: 3.2 cm. Pressure 48.
Right atrium: 7.1x4.1 cm.
Mitral valve: the movement of the leaflets is multidirectional. Valve
opening 2.6 cm. FC 3.3 cm. V peak 1.39 m/s. Pg peak 7.7 mmHg.
Regurgitation grade I. Arrhythmia.
Aortic valve: tricuspid. Valve opening 1.8 cm. V peak 1.85 m/s. Pg
peak 13.6 mmHg.
Tricuspid valve: FC 3.1 cm, degree of regurgitation II .
Pulmonary valve: degree of regurgitation 0 I.
Pulmonary artery: diameter 2.4 cm.
Conclusion: dilatation of the right heart. Increased pressure in the
right side of the heart. Slight hypertrophy of the walls of the left ventricle.
Sclerotic changes in the leaflets of the aortic and mitral valves. Mitral
regurgitation stage I Tricuspid regurgitation stage II. Function is within
normal limits. Arrhythmia. There is no impairment of contractility at rest.
Ultrasound of the kidneys from 04/08/14
Right 118x58 mm
The contour is smooth
Parenchyma of normal thickness
Thinning 17mm
The sinuses are not dilated,
compacted
The collecting system is not dilated
Concrete - no
Focal formations - no
Right 118x57 mm
The contour is smooth
Parenchyma of normal thickness
Thinning 18mm
The sinuses are not dilated,
compacted
The collecting system is not dilated
Concrete - no
There are focal formations. In the
lower part there is an anechoic
formation 5.8x6.5 cm. In the sinus
there is an anechoic formation 2.1
cm (cysts)
Conclusion
diffuse changes in the sinuses, cysts of the left kidney.
Ultrasound of the liver from 04/08/14
The liver is not enlarged. The thickness of the right lobe is 108, left
62, caudate 23. CVR 10. The contour is smooth. The structure is finegrained, heterogeneous. Echogenic density is increased. Sound
conductivity is not changed. There are no focal formations. Hepatic veins
up to 9 mm. Portal vein 1.1 (up to 1.4), IVC 2.4 (up to 2.5),
hepatocholedocus 6 (6 - 8). The intrahepatic ducts are not dilated.
The gallbladder is 8.5x2.4 cm. Pear-shaped. The wall is compacted,
not thickened. Small stones in the cavity.
Pancreas. Head 2.5 cm, body 1.4 cm. The contour is even. The
structure is heterogeneous. Echogenic density is increased. The duct of
Wirsung is not dilated. There are no focal formations.
Conclusion: diffuse changes in the liver. Signs of chronic calculous
cholecystitis. Diffuse changes in the pancreas.
Ultrasound of the thyroid gland from 04/08/14
The location is retrosternal, difficult to see. External contours are
unclear. The right lobe is poorly visible. Width 13 mm, thickness 17 mm,
length 40 mm. The left lobe is 15 mm wide, 16.6 mm thick, 33 mm long.
Isthmus -. Total volume 8.16 cm3. Echogenicity is reduced, uneven. The
echostructure is heterogeneous.
On the left, in the area of the isthmus, a round echo-heterogeneous
formation of 3.0x3.0 cm with blood flow signals (node) is visualized. In the
left lobe, a hypoechoic formation 1.0 cm in diameter and a hyperechoic
formation 1.0 cm in diameter (nodes) are visualized.
The vascular pattern is not enhanced.
Conclusion: visualization is reduced, dimensions may not be
accurate. Total volume 8.61 cm3. Diffuse changes in the thyroid gland. A
node in the isthmus region is the nodes of the left lobe.
. Clinical diagnosis
Data from additional research methods do not contradict the
preliminary diagnosis.
Echo-ECG revealed thickening of the posterior wall of the left
ventricle to 12-13 mm, thickening of the RV to 12-13 mm, which confirms
left ventricular hypertrophy syndrome.
A biochemical blood test reveals hypercholesterolemia, which is one
of the main risk factors in the development of hypertension; the creatinine
level indicates that there is kidney pathology.
Data found on the ECG, biochemical blood test, Echo-CG, and
ultrasound of the abdominal organs confirm stage 3 hypertension, risk 4.
ECG data confirm cardiac arrhythmia such as permanent atrial
fibrillation.
Based on these additional research methods, the main clinical
diagnosis can be made : hypertension, grade 3, stage 3, risk 4 (abdominal
obesity, left ventricular hypertrophy, hypercholesterolemia). Hypertensive
crisis from 04/02/14, type 1, uncomplicated.
Related: LDCs according to the PFFP type. CHF IIb FC.
arterial hypertension treatment
9. Differential diagnosis
The leading syndrome in hypertension is arterial hypertension
syndrome. This syndrome also occurs in secondary arterial hypertension.
Secondary arterial hypertension can be assumed if hypertension develops
in young people, there is an acute development and rapid stabilization of
hypertension at high levels, resistance to antihypertensive therapy, and a
malignant course of hypertension.
. Vasorenal hypertension is symptomatic hypertension caused by
renal ischemia due to impaired patency of the renal arteries. The disease
occurs before the age of 30 or after 50 years, and there is no family history
of hypertension. Characterized by rapid progression of the disease, high
blood pressure, resistance to treatment, vascular complications, the
following symptoms are identified:
noise in the projection of the renal arteries
hypokalemia
asymmetry of the kidneys on ultrasound.
. Pheochromocytoma is a catecholamine-producing tumor. In 50% it
is constant, in 50% it is combined with crises (paroxysmal form). In the
paroxysmal form, the occurrence of hypertensive crises is facilitated by
emotional stress, uncomfortable position of the body, and palpation of the
tumor. The attack occurs suddenly, accompanied by chills and a feeling of
fear.
. Hypertension in primary aldosteronism has the following features:
changes on the ECG in the form of flattening of the T wave
muscle weakness
polyuria
headache
polydipsia
parasthesia
convulsions
myalgia
the leading clinical and pathogenetic sign is hypokalemia.
. Hypertension in hypothyroidism - high diastolic blood pressure,
decreased heart rate and cardiac output.
. Characteristic signs of hyperthyroidism are an increase in heart
rate and cardiac output, predominantly isolated systolic hypertension with
normal diastolic pressure.
. Etiology
The reasons for the development of headache are unclear. Among
the factors contributing to the development of the disease are:
hereditary constitutional features associated with the pathology of
cell membranes;
nervous-emotional tension;
occupational hazards (noise, constant strain on vision, attention);
dietary habits (salt overload, calcium deficiency);
age-related changes during menopause;
traumatic brain injuries;
chronic intoxication (alcohol, smoking);
violation of fat metabolism (excess body weight, dyslipoproteinemia).
In the occurrence of hypertension, the role of burdened heredity is
great. Against its background, the listed factors in various combinations or
separately can play an etiological role. Cardiac output and total peripheral
resistance are the main factors determining blood pressure levels. An
increase in one of these factors leads to an increase in blood pressure and
vice versa. In the development of hypertension, both internal humoral and
neurogenic, as well as external factors are important. In patients with
hypertension, the prognosis depends not only on blood pressure levels. The
presence of associated risk factors, the degree of involvement of target
organs in the process, as well as the presence of associated clinical
conditions are no less important than the degree of increase in blood
pressure, and therefore stratification of patients depending on the degree
of risk has been introduced into the modern classification.
Main risk factors:
men > 55 years old;
women > 65 years of age, menopause in women;
cholesterol > 6.5 mmol/l, HDL <1 in men, <1.2 in women;
family history of early cardiovascular diseases in women <65 years
old, in men <55 years old;
diabetes.
Additional risk factors:
reduction in HDL cholesterol <1 in men, <1.2 in women;
increased LDL cholesterol;
microalbuminuria in diabetes;
impaired glucose tolerance;
obesity;
sedentary lifestyle;
increased fibrinogen levels;
socio-economic risk group.
Pathogenesis
The pathogenesis of hypertension is determined by a violation of the
physiological mechanisms of blood pressure formation. Hemodynamic
changes include:
an increase in cardiac output or cardiac output through changes in
other hemodynamic quantities (increased circulating plasma volume).
increase in the volume of peripheral vascular resistance
reduction of elastic stress in the walls of the aorta and its large
branches
increased blood viscosity.
Hemodynamic changes arise due to dysfunction of the central and
peripheral neurohumoral systems of blood pressure regulation. Short-term
neurohumoral systems include: baroreceptor reflex, including
baroreceptors of large arteries, brain centers, sympathetic nerves,
resistive vessels, capacitive vessels, heart blood pressure. The renal
endocrine circuit includes the kidneys (juxtaglomerular apparatus, renin),
angiotensin-1 and -2, resistive vessels, blood pressure.
The integral neurohumoral system of blood pressure regulation
provides long-term control over its level:
- kidneys - adrenal cortex (aldosterone) - conservation of sodium ions
- body fluid - bcc - blood pressure;
depressor mechanisms concentrated mainly in the medulla of the
kidney, as well as in the walls of resistive vessels.
One of the consequences of a long-term increase in blood pressure is
damage to internal organs, the so-called target organs. These include:
heart, brain, kidneys, blood vessels. Heart damage in hypertension can
manifest itself as left ventricular hypertrophy, angina pectoris, myocardial
infarction, heart failure and sudden cardiac death; brain damage thrombosis and hemorrhage, hypertensive encephalopathy and damage to
perforating arteries; kidneys - microalbuminuria, proteinuria, chronic renal
failure; vessels - involvement in the process of the vessels of the retina,
carotid arteries, aorta (aneurysm). In untreated patients with hypertension.
Heart damage due to hypertension.
There are 4 stages of hypertensive heart disease (according to E.D.
Frolich):
- there are no obvious changes in the heart; according to Echo-CG
data, there are signs of impaired diastolic function of the left ventricle,
which develop before impaired systolic function;
- enlargement of the left atrium;
- presence of left ventricular hypertrophy;
- development of CHF, possible addition of ischemic heart disease.
CHF is a condition that inevitably occurs with hypertension and ultimately
leads to death. IHD can occur not only due to damage to the coronary
arteries, but also due to microvasculopathy.
Kidneys in arterial hypertension .
The condition of the kidneys is generally assessed by the glomerular
filtration rate. In uncomplicated hypertension, the glomerular filtration rate
is usually normal. In severe or malignant hypertension, GFR is significantly
reduced. Since constant excess pressure in the glomeruli leads to
dysfunction of the glomerular membranes, it is believed that GFR in long-
term hypertension depends on the level of blood pressure: the higher the
blood pressure, the lower the GFR. In addition, when elevated blood
pressure levels persist, constriction of the renal arteries occurs, which
leads to early ischemia of the proximal convoluted tubules and disruption
of their functions, and then to damage to the entire nephron. Hypertensive
nephrosclerosis is a characteristic complication of hypertension, which is
manifested by a decrease in the excretory function of the kidneys. The
main indicators of the involvement of the kidneys in the pathological
process in hypertension are the creatinine content in the blood and the
protein concentration in the urine.
Vessels in arterial hypertension
Increased total peripheral vascular resistance plays a leading role in
maintaining high blood pressure. At the same time, the vessels also serve
as one of the target organs. Damage to small arteries in the brain can lead
to strokes, and damage to the arteries of the kidneys can lead to
dysfunction. The presence of hypertensive retinopathy, diagnosed by
fundus examination, is of great importance for the prognosis of the disease.
There are 4 stages of hypertensive retinopathy:
stage - slight narrowing of arterioles, angiosclerosis;
stage - more pronounced narrowing of arterioles, arteriovenous
crossings, no retinopathy;
stage - angiospastic retinopathy, hemorrhages, retinal edema;
stage - papilledema and significant vasoconstriction.
11. Treatment plan and rationale
The goal of treatment of arterial hypertension is not only to reduce
high blood pressure, but also to protect target organs, eliminate risk
factors (smoking cessation, lower blood cholesterol concentrations, reduce
excess body weight) and, as an ultimate goal, reduce cardiovascular
morbidity.
Treatment plan for hypertension
control of blood pressure and risk factors, achieving target blood
pressure;
lifestyle changes;
continuous drug therapy.
.
Non-drug treatment
Basic measures: diet, reduction of excess body weight, sufficient
physical activity.
Diet: limit the consumption of table salt to less than 6 g per day (but
not less than 1-2 g per day, since in this case compensatory activation of
the RAAS may occur). Limiting carbohydrates and fats, which is important
for the prevention of coronary heart disease, the likelihood of which
increases with coronary artery disease. Increasing the potassium content
in the diet may help lower blood pressure. Quitting alcohol intake can help
lower blood pressure.
Physical activity: sufficient cyclic physical activity (walking) in the
absence of contraindications from the heart (presence of coronary artery
disease), leg vessels (obliterating atherosclerosis, varicose veins), central
nervous system (cerebrovascular accidents) reduces blood pressure, and
at low levels can normalize it.
Other methods of treating hypertension also retain their importance:
psychotherapy, relaxation, acupuncture, massage, physiotherapeutic
methods (electrosleep, DDT, hyperbaric oxygenation), water procedures
(swimming, shower), herbal medicine (hawthorn fruits, motherwort grass,
immortelle flowers).
Drugs treatment
Amlodipine tab morning 10 mg 1 time a day for 14 days
bisoprolol tab morning 5 mg 1 time a day for 14 days
Rosuvastatin tab evening 10 mg 1 time a day for 14 days
Telmisartan tab morning 80 mg 1 time a day for 14 days