internal medicine sheet # 3 - Amnah $defat

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internal medicine sheet # 3 - Amnah $defat

Post by Shadi Jarrar on 18/10/2011, 3:45 am

" بسم الله الرحمن الرحيم "
Internal medicine .
Lec.# 3
Done by : Amnah shdiefat
- In the past we considered 140/90 is normal blood pressure but now , 140/90 or 135/85 with other risk factor such as diabetes ,with renal involvement and protein urea are considered as hypertension( not normal) , and in the future the range of hypertension will be lower than 140/90.
- Hypertension is very common disease and this is The importance of this disease ,nearly 25% of adult have hypertension either they know or not, ( y3ne mn kl 4 fe wa7d 3ndo hypertension ). So the concept / terms " AWARNESS"( y3ne I know or don’t know if I have hypertension ).
- In the begin of 90th 50% of people have hypertension and they didn’t know that because the hypertension is silent disease (no symptom )so any one above18yrs old may have hypertension and he not aware because he not measure his blood preasure and the hypertension is silent disease ( no symptom).
- Awareness , treatment , control . 50% of patient didn’t know that they hypertension patient.50% of patient know that have hypertension dose not seek treatment .50% of those patient have uncontrolled treatment .
- The dr. show us figure about ( awareness, treatment , control ) the three term improved and increased through the last years.
- The problem now that the percentage of the hypertension increase when we compare it with other disease because the type of lifestyles ( klna nrkb searat b6l 7da ymshe . dymn 8a3den 3 computers or videos on TV w bnokl chips. all these thing increase blood pressure ). And we decrease the definition of normal blood pressuer, when I said 160/90 is normal differ from when I said 140/90 is the normal .(kl ma feha al shre7ah btzeed).
- The hypertension is very common disease and dangerous because its effect on kidney and CVS , it’s the major cause of stroke ( CVA), heart failure ,coronary artery disease , ischemic heart disease, second cause of renal failure( b3d 2l diabetes ).so its dangerous disease and its complication is very dangerous .( silent disease , dangerous disease ) .
If we decrease the blood pressure we decrease the % of heart failure 50% , the stroke 40% ,and the MI 25% .( she 3jeeb jedn )
- If you have a headache that’s dose not mean you have a hypertension because the headache is a common symptom, may have an increase in blood pressure because the stress , so there's an association.
- The idea that is the patients should always take the medication at time and don’t skip it because they filet improving their health, remember the hypertension is silent killer, there's no symptom unless the blood pressure raised above 200.
- The hypertension is sign we know it by measure the blood pressure ,to measure the blood pressure we should chose the suitable time and the suitable instruments in the suitable way .
- The smoking is increase blood pressure, every one cigarette increase blood pressure( systolic 10. diastolic 5) for about half an hour.
- Variability of blood pressure mean the blood pressure differ with every heartbeat , varies in individual from moment to moment . in the clinic the patient already may have stress , or any reason may give rise the blood pressure (panic ,anger ,uncomfortably )so the measure of blood pressure may not be accurate .
- Now there's an electronic device we use it to measure blood pressure accurately instead of mercury manometer

Another electronic device Ambulatory blood pressure monitoring (ABPM) measure blood pressure at regular intervals,the devices take readings every half hour throughout the day and night have been used for identifying and mitigating measurement problem like white coat hypertension , expect for sleep (if someone have hypertension during sleeping )

Why use ambulatory blood pressure monitoring?

§ To exclude "white coat" hypertension.

§ End-organ damage is more closely correlated with ambulatory blood pressure (ABP) than with clinic blood pressure readings.

§ ABP may be a better predictor of cardiovascular events and mortality than clinic blood pressure readings.

§ Patients with hypertension whose nocturnal (sleep) blood pressure remains high (< 10% lower than daytime average) may have a worse prognosis.

§ ABP provides a 24-hour profile, allowing assessment of clinic effects, drug effects, work influence, etc

- if we compared between clinical measure , home measure and APM measure :

*prognosis " outcome of patient " most effect is AMP measure.

*Diagnostic use, the most effect is AMP .

*Evaluation of treatment, the most effect is home measurements ( ask the patient to measure the blood pressure before take the pill to assure that the amount of medication is correct or not .)

- the patient has important role in the treatment .

- in normal physiology the blood pressure fall during sleep "dipping" and after wakeup the blood pressure rise "surge" ..

- systolic hypertension is defined as an elevated systolic blood pressure. If systolic blood pressure is elevated (>140) with a normal diastolic blood pressure (<90), it is called "isolated systolic hypertension".

- we have two type of reading blood pressure measurement :
1 - clinic blood pressure reading."office"
2 - out clinic blood pressure reading ." out office" (casual )
*If 1 & 2 are high in this case there's no problem and we can diagnose and treate the patient .
* if 1 & 2 are normal in this case also no problem and that mean the patient may be treated effectively or he doesn't have hypertension .
* if the clinic reading is high and the out of clinic is normal , here we have a problem , this is what we called White coat hypertension ,office hypertension

This is a benign condition , most common ( ma be5of ) they need follow up because these people at high risk to develop hypertension and at this time there's no problem for these people .
* if the clinic reading is normal and the out of clinic reading is high ,here the problem and that’s what we called Reverse white coat , mask hypertension.
- 10-20 % of hypertension patients have mask hypertension when we talk about common disease( hypertension) affect about 25% of population we means that nearly 2-3% of population have mask hypertension ,difficult to diagnose this type and the only way to diagnose this type is by measuring blood pressure out of the clinic by using ABPM or home monitoring .
- Reverse hypertension is the most type of hypertensions that develop complication such as heart failure ( because we don’t diagnose this type in the clinic ,so when the patient come to the clinic we ask him if he has a device that measure blood pressure( its not expensive, easy to use ,we can measure/ check up blood pressure for family and its very important device for patients life), in this case measuring the blood pressure out of the clinic is mandatory ).
- in all cases the clinic reading is not useful as home reading or may be wrong. So we can replace the clinic reading by home reading .
* after the patient diagnosed as hypertension patient we should determine the reason of the disease ,
if there's no reason that’s mean its primary "essential" hypertension -genetics factors , environment – about 90%of patients have primary HTN.
Secondary hypertensions means there are reasons for the disease such as hormone disturbance , renal disease ,
* the primary HTN is interaction of three things :
1- genetics, environmental factors "stress" .
2- Obesity
3- smoking , age
- in ethnic group in south America the hypertension is rare disease. because these ethnic group don’t use salt in their diet .so there's a strong relationship between salt and hypertension and as part of treatment we decrease the amount of salt in the diet .
- We can determine blood pressure ( normal & abnormal ) depending on the guidelines of … ??.
- the normal blood pressure is 120/80 , 140/90 is abnormal blood pressure (hypertension ) between these two percents the blood pressure is described as prehypertension ( not normal or abnormal , and it carry higher risk . if the patient has diabetes or renal failure then he considers as hypertension patient although his blood pressure is between 120/80 &140/90 .)

Top number (systolic) in mm Hg

Bottom number (diastolic) in mm Hg
Your category*
What to do**
Below 120
Below 80
Normal blood pressure
Maintain or adopt a healthy lifestyle.
Maintain or adopt a healthy lifestyle.
Stage 1 hypertension
Maintain or adopt a healthy lifestyle. If blood pressure goal isn't reached in about six months, talk to your doctor about taking one or more medications.
160 or more
100 or more
Stage 2 hypertension
Maintain or adopt a healthy lifestyle. Talk to your doctor about taking more than one medication.
- the bigger # if it diastolic or systolic is that one determine the stage of hypertension .
- the devices used to measure blood pressure have evolved ,some of them have color coded for the stages of hypertension , high blood pressure …red color ,prehypertension …yellow.
- if the patient in stage one he need one drug , and if he in stage two he need two drug at the begin .
- when the patient come to the clinic we take proper history and good physical examination, include fundoscopic examination( examine blood vessels in retina ,because it is small it is the first affected by increasing blood pressure) .
- the history give you information about the type of blood pressure ,ex. Female 30years old has high blood pressure at this age the most common cause of hypertension is the contraceptive pill , you should ask the patient directly if she take contraceptive pill or not because she doesn't consider it as medication .
- mandatory investigation for high blood pressure patient .
1- cholesterol level
2- ECG
3- urine analysis .
4- fundoscopy .
- CBC & CBM & chest X-ray ( kano zaman bs hla 3lahm X ) not mandatory investigation for hypertension patient .
- urine analysis : the most important test also it not expensive and give us important information &( ma bewaje3).
-all patient has hypertension should do urine analysis .
- there's a strong relationship between blood pressure and hypertension (mtel 3la8et al bedh bel jajeh .!!!).
- the blood pressure affect the kidney & the kidney increase blood pressure ,
- if the hypertension patient doesn't treat may develop heart failure, renal failure , MI , stroke .so it’s a very serious disease .
- if the patient is pregnant lady with BTA may develop toxemia ( btro7 feha hea w al janeen).
- the complication of hypertension need at least three month to developed in patient who don’t seek treatment .
- top emergency , toxemia in pregnant , MI ,congestive heart failure , pulmonary edema , those patient entrance ICU and monitoring blood pressure & measure it directly from the artery and giving drug IV to decrease blood pressure ."end organ damage "
- urgency is less dangerous than emergency , the patient enter the hospital and follow up . " no organ damage " .
- A hypertensive crisis is divided into two categories: urgent and emergency. In an urgent hypertensive crisis, your blood pressure is extremely high, but your doctor doesn't suspect you have any damage to your organs. In an emergency hypertensive crisis, your blood pressure is extremely high and has caused damage to your organs. An emergency hypertensive crisis can be associated with life-threatening complications
- malignant hypertension if the patient has papilledema .
-resistant hypertension" congenital" is high blood pressure that does not respond to treatment.
- gestational hypertension : hypertension in pregnant with protein urea .
- un fear to deal with female as male , the blood pressure in female is lower than male , it is normal if you find the blood pressure for female is 90/60 , maybe impossible to find this percent in normal male . out of record, this is the Dr. opinion
- treatment of hypertension :
1- life style modification .reduce the amount of salt in diet ,and sweet ,waking ,eating fruit & vegetables , reduce fast food , stop smoking , lose excess weight (BMI : body mass index ).
2- group of medication :
- diuretic ,
- Bata blockers ,
- alpha blockers
- CCB " calcium channel blockers
- vasodilator
- ARB " Angiotensin receptors blockers"
- ACE inhibitor " Angiotensin converting enzyme inhibitors" .
- rennin inhibitor .
* start treatment in old patient by diuretics , if young patient start with the last three group.
* the most important cause of resistant hypertension is non-compliance then drug availability in hospitals( yom feh dwa w 10 ma feh ) ,expensive drug .

عِلمُ العليم وعَقلُ العاقل اختلفا * من ذا الذي منهما قد أحرز الشرفا
فالعلمُ قالَ أنا أحرزتُ غايَته * والعقلُ قالَ أنا الرحمنُ بي عُرفا
فأومَأ العلمُ ايمائاً وقالَ له * بأيُنا الرحمنُ في فرقانهِ اتصَفا
فبانَ للعقلِ أنّ العلمَ سيده * فقبّل العقلُ رأسَ العلمِ وانصَرفَا
Shadi Jarrar
مشرف عام

عدد المساهمات : 997
النشاط : 12
تاريخ التسجيل : 2009-08-28
العمر : 26
الموقع : Amman-Jordan

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