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ЗмістII. Learning Objectives
IV. Theory Topics on the Subject
Teaching Guidelines for Practice Activities on
dizziness Displacing of heart border laterally
First aid at hypertension stroke
Diagnostic Algorithm For
Increase in excretion 17-hydroxycorticosteroids in 24 hours' urine
Advice of endocrinologist Increase of aldosterone level in plasma
4 proteinuria, hematuria, leukocyturia
constriction of renal artery on angiogram
Classification of arterial hypertension depending on presence and severity of target-organs damage
I. Importance of the subject:
Arterial hypertension (АH) is one of the most common reasons of a myocardial infarction and the disorder that results in early invalidity and lethality of patients. So timely diagnostics of АH became the major task not only for therapeutists, but also doctors of each speciality. During differential diagnostics of АH it is necessary to differentiate primary АH - essential hypertension (EH) and secondary (symptomatic) АH. Despite of the certain similarity, these diseases are different by etiology, a pathogenesis, clinical features and management. Secondary hypertension is potentially curable disease when used adequate therapy. New powerful drugs could slow down the progression of EH. So correct diagnostics and management of such patients determine the prognosis of the disease, duration and quality of patients’ life.
To prove the importance of the topic let’s discuss the clinical observation.
Patient В., 45 years old, was admitted to therapeutic department with complaints of a headache, palpitation, elevation of blood pressure (BP), chest discomfort. She took Raunatinum occasionally, but there were repeated attacks of elevation of BP up to 200/100 mm Hg with tachycardia, segment ST depression in leads V5-V6. In hospital adequate doses of angotensine converting enzyme (ACE) inhibitors and beta-blockers were prescribed. Chest discomfort disappeared, the BP stabilized at a level of 130/80-120/80 mm Hg, heart rate - 75-85 beats per minute.
If the importance of the subject has been understood, proceed to studying the learning objectives.
Key objective: to develop skills in making a differential diagnosis of arterial hypertension, and planning a patient management.
The information necessary for reviewing and revising the basic knowledge and skills can be found in the following references:
Pre-Practice Knowledge and Skills Test Questions
Q1. Patient А., 61 years old, complains of breathlessness, chest pain, cough and dyspnea attacks in horizontal position, edemas of legs. What complaint is typical for cardiovascular disease?
B) chest pain;
C) cough and dyspnea attacks in horizontal position;
D) edemas of legs;
E) all above-listed.
Q 2. Patient D., 20 years old, suffering from AH has systolic murmur at the right hypochondrium. Doctor has suspected a right renal artery stenosis. What instrumental method can confirm this diagnosis?
А) renal angiography;
B) excretory urography;
C) plain abdomen radiography;
D) urine analysis;
E) Addis sediment count.
Q 3. On sphygmomanometry BP of 160/40 mm Hg was registered. On auscultation diastolic murmur on aorta was revealed. What diagnosis are these symptoms typical for?
А) aortic insufficiency;
B) mitral insufficiency;
D) mitral valve prolapse;
E) mitral stenosis.
Q 4. In urine analysis of patient E., 34 years old, suffering from secondary (renal) АH, the following changes were found: relative density -1015, protein - 1,0 g/l, erythrocytes - 1/2 of vision field, leucocytes - 2-3 in vision field, hyaline cylinders - 3-4 in vision field. What symptoms are present?
А) proteinuria, hematuria, cylindruria.
B) proteinuria, hematuria, leukocyturia;
C) proteinuria, leukocyturia;
D) cylindruria, leukocyturia;
E) cylindruria, leukocyturia, hematuria.
Q 5. Patient А., 42 years old, suffering from EH, with high elevation of BP suddenly experienced a dyspnea, bubbling respiration, foamy sputum, on auscultation - large bubbling rales in both sides of lungs. What condition are these symptoms typical for?
А) acute insufficiency of left ventricle;
Б) acute insufficiency of right ventricle;
В) asthmatic status;
Г) total heart failure;
Д) spontaneous pneumothorax.
Q 6. Patient К., 48 years old, was prescribed amlodipine for treatment of EH. What mechanism of action is typical for this drug?
А) peripheral vasodilation;
B) decrease in heart contractility;
C) decrease in heart rate;
D) decrease in blood volume;
E) all above-listed.
Key Answer 1.
Right answer E) - all above-listed complaints are typical for cardiovascular disease: breathlessness, cough and dyspnea attacks in horizontal position, edemas of legs – are signs of heart failure, chest pain is a symptom of angina pectoris.
Key Answer 2.
Right answer А) - excretory urography allows to visualize pyelocaliceal system of kidneys; survey plain abdomen radiography does not give the information about renal vessels, the urine analysis and Addis sediment count show concentration function of kidneys and contents of leucocytes and erythrocytes in urine. Only renal angiography can show renal artery stenosis.
To reach the learning objectives it is essential to master the following theory issues:
The information necessary for mastering the theory issues may be found in the following references:
Then, proceed to solving some test questions and checking test question 5 with the key answer.
Q 1. Patient Е., 36 years old, complains of paroxysmal headache, tremor, palpitation. On examination paroxysmal elevation of BP with hypercatecholaminemia, hyperglycemia and a leukocytosis were revealed. What diagnosis is the most probable?
B) Conn's syndrome;
C) essential hypertension;
D) Itsenko-Cushing syndrome;
E) Takayasu's disease.
Q 2. On examination of patient C., 16 years old, developmental lagging of lower half of the body, systolic murmur and accent of 2-nd tone on aorta, elevated BP on arms and decreased BP on legs were observed. The coarctation of aorta was suspected. What diagnostic method can confirm this diagnosis?
E) chest roentgenography.
Q 3. Patient G., 20 years old, complains of headache, fever, arthralgias, weight loss. On examination: systolic murmur on aorta, different levels of BP on extremities. What disease are these symptoms typical for?
A) Takayasu's disease.
B) coarctation of aorta;
D) essential hypertension;
E) Conn's syndrome;
Q 4. Patient К. complains of weakness of left leg and arm, flatness of right nasolabial fold. BP-230/120 mm Hg. He suffers from essential hypertension for 10 years, takes hypotensive drugs irregularly. What drug will you administer first of all?
А) Sodium nitroprussidum;
Q 5. In patient D., 51 years old, for the first time EH was diagnosed. Despite of nonmedicamental methods of correction AH, the BP was kept on level of 150/80 - 160/90 mm Hg, heart rate 65-70 beats per minute. What drug do you start medicamental treatment with?
B) ACE inhibitors;
C) alkaloids of Rauwolfia;
D) Ca channel blockers;
E) α - adrenoblockers.
Key answer 5.
Right answer А) - if nonmedicamental methods aren’t effective it is necessary to use drugs. In this case diuretics are the drugs of the first line for АH treatment.
At the beginning of the class, the instructor gives tests to check and correct the pre-practice level of knowledge. Then, the students start to see patients under the instructor’s supervision after which the students give an analysis of the practice patients and the instructor checks the mastering of the practice topics. A final tests are provided to strengthen the knowledge gained. At the end of the class, the instructor reviews the students’ self-learning activity, considers and corrects the students’ typical mistakes with a subsequent improvement of knowledge and skills.
Flow Chart of
Main symptoms and syndromes
Accent of S2
Classification of Blood Pressure in Adults
BP (mm Hg)
≥ 160 (systolic)
≥ 100 (diastolic)
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