Use of oral contraceptives or other drugs, such as cocaine, epoetin alfa, and cyclosporine, steroids.

Signs and symptoms

• Cerebral symptoms: headache, dizziness, buzzing in the ears and head, irritation (due to disorders of vessel tone, their widening is changed spasm. It results in disorders of cerebral circulation. There is an irritation of the cerebral vessels by increased BP).

• Cardiac symptoms: heart pain, palpitation and interruption of the heart bit

• General symptoms: fatigue, sleep disorders, decreasing work ability

Visual examination: flush of the face and sclera. Pulse is hard, intense.

Apex bit is heaving, undisplaced to the left, and resistant. The left border of relative heart dullness drifts left due to hypertrophy left ventricle.

On auscultation diminished S1 (muscle component) on the apex, and accented S2 on the aorta (high pressure) are heard.

Investigations

Serial blood pressure measurements that are greater than 140/90 mm Hg in people under confirm hypertension

We can use a dairy BP monitoring: measuring BP every 15 min during day and every 30 min during night with following computer reading.

Ophthalmoscopy reveals arteriovenous nicking and, in hypertensive encephalopathy, papilledema.

Hypertensive retinopathy

I. Tortuous arteries with thick shiny walls (silver or copper wiring)

II. a-v nipping (narrowing where arteries cross veins)

III. Flame haemorrhages and cotton wool spots

IV. Papilloedema.

• Urinalysis: The presence of protein, red blood cells, and white blood cells may indicate glomerulonephritis.

Only proteinuria means renal complication of hypertension

• Excretory urography: Renal atrophy indicates chronic kidney disease; one kidney that is more than 5/8 (1.5 cm) shorter than the other suggests unilateral kidney disease.

• Serum potassium: Levels less than 3.5 mEq/L may indicate adrenal dysfunction (primary hyperaldosteronism).

• Blood urea nitrogen (BUN) and serum creatinine levels: A BUN level that is normal or elevated to more than 20 mg/dl and a serum creatinine level that is normal or elevated to more than 1.5 mg/dl suggest kidney disease.

Other tests help detect cardiovascular damage and other complications:

• Electrocardiography may show left ventricular hypertrophy or ischemia (depressed ST segment and negative T-wave in I, II, AVL, V_4-6).

• Chest X-ray may show cardiomegaly.

• Echocardiography may show left ventricular hypertrophy. There are thickened left ventricular walls, interventricular septum.

• Renal arteriography may show renal artery stenosis.

Classification and clinical presentation of the essential hypertension:

• I stage – episodic elevation of BP with cerebral, cardiac and general symptoms without any other signs except high BP

• ІІ stage: Permanent symptoms and signs of affect of the target organs without their failure:

Heart – left ventricle hypertrophy ( sings, ECG, Ehocardiography, X-Ray)

eye grounds- hypertensive retinopathy I-II

Kidney – proteinuria, increased blood creatinine (male 115-133 mcmol/l or 1,3-1,5 mg/dl, female 107-124 mcmol/l or 1,2-1,4 mcmol/l)

• ІІІ stage - Permanent symptoms and signs of affect of the target organs with their failure (complicated stage)

Heart – myocardial infartion, heart failure ІІ-ІІІ st.

Brain - cerebrovascular accident, chronic hypertensive encephalopathy ІІІ st. and vassel dementia

Eye grounds- hypertensive retinopathy III- IV

Kidney – proteinuria, increased blood creatinine (male >133 mcmol/l or >1,5 mg/dl, female >124 mcmol/l or >1,4 mcmol/l), chronic renal failure

Vassels– aortic dissecting aneurysm

Clinical presentation of the hypertensic crisis

Sudden increasing BP in the patients with hypertension which is accompanied significant change in the target organs.

There are two types of the hypertensic crisis I type (adrenal crisis) and II type (nor-adrenal crisis)

І type

• Occur during I or II stage of hypertension

• Fast beginning (several hours)

• SBP > DBP

• Intensive vegetative disorders (headache, trembling, palpitation, flush, frequent urination)

• Visual examination: flush of the face and sclera

• Duration: several hours, usually complications are absent.

ІІ type

• Occur during II or III stage of hypertension

• Slow developing (dozens hours or several days)

• DBP>SBP

• Continuing dairy

• Symptoms: disorders of eyesight, limb numbness, nausea, vomiting, headache, nose bleeding

• There are the target organs complications: brain: cerebrovascular accident, retina: blindness, heart: myocardial infarction, acute heart failure, pulmonary oedem,kidneys: proteinuria, edema and renal failure.

Reference source

Olga Kovalyova, Tetyana Ashcheulova Propedeutics to internal medicine, Part 1. – Vinnytsya: NOVA KNYHA, 2006. – p. 220-227

Materials for self-control (added)

1. Which level of the blood pressure is corresponded to mild hypertension?

A. > 140/< 90 mm Hg.

B. 140-159/90-99 mm Hg.

C. 160-179/100-109 mm Hg.

D. ≥ 180/≥ 110 mm Hg.

E. ≥155/≥100 mm Hg

2. Risk factors of essential hypertension:

1. Family history, race (blacks), stress, obesity, a high intake of saturated fats or sodium, use of tobacco, sedentary lifestyle.

2. Family history, stress, obesity, a high intake of saturated fats or sodium, use of tobacco, hepatitis, sedentary lifestyle.

3. Family history, stress, obesity, a high intake of saturated fats or sodium, cardiac arrhythmia, sedentary lifestyle.

4. Stress, obesity, a high intake of saturated fats or sodium, use of tobacco, hepatitis, sedentary lifestyle.

5. Family history, race (blacks), cardiac arrhythmia, sedentary lifestyle.

3. What arterial pressure is corresponded to moderate hypertension?

A. > 140/< 90 mm Hg.

B. 140-159/90-99 mm Hg.

C. 160-179/100-109 mm Hg.

D. ≥ 180/≥ 110 mm Hg.

E. ≥155/≥100 mm Hg

4. What are the pulse properties at patients with arterial hypertension?

A. Hard, intense.

B. Hard.

C. Frequent.

D. Intense, frequent.

E. Arrhythmic, slow.

5. What is the commonest symptom at patients with essential hypertension?

A. Sleep disorders.

B. Headache.

C. Myalgia.

D. Arrhythmia.

E. Edemas

6. How are the heart borders displaced at patient with the 2^nd stage of essential hypertension?

A. Shift to the right.

B. Shift to the left.

C. Shift to the left and up.

D. Shift to the right, left and up.

E. Not changed.

7. During auscultation of patients with prolonged arterial hypertension you can hear:

A. Diminished S1 at the apex, and accented S2 at the aorta.

B. Loud S1 at the apex, and accented S2 at the aorta.

C. Increased S1 at the apex, and diminished S2 at the aorta.

D. Diminished S1 at the apex and S2 at the aorta.

E. Normal heart sounds

8. ECG sign of the left ventricular hypertrophy:

A. High R at the V3, V4.

B. High R at the V1, V2.

C. High R at the V5, V6.

D. Deep S at the I lead.

E. High R at the III lead.

9. Which organs are considered target at the patients with arterial hypertension?

A. Heart, liver, lungs and brain

B. Liver, brain, kidney, eyes

C. Heart, brain, kidney, eyes, vessels

D. Heart, liver, lungs and kidney

E. Liver, brain, kidney, eyes, heart.

10. Criterions of the ІI stage of essential hypertension:

A. Episodic elevation of BP with cerebral, cardiac and general symptoms without any other signs except high BP.

B. Permanent symptoms and signs of the target organs affecting without their failure.

C. Permanent symptoms and signs of the target organs affecting with their failure (complicated stage)

D. Frequent hypertonic crisis.

E. Lack of effect of the medication treatment.

11. What blood pressure is corresponded to severe hypertension?

A. > 140/< 90 mm Hg.

B. 140-159/90-99 mm Hg.

C. 160-179/100-109 mm Hg.

D. ≥ 180/|≥ 110 mm Hg.

E. >160/>100 mm Hg.

12. How is color of skin changed at the patient with arterial hypertension?

A. Flush of the face and sclera.

B. Flush of the foot.

C. Flush of the stomach.

D. Flush of the back

E. Flush of the hands

13. What blood pressure is corresponded to isolated systolic hypertension?

A. > 140/< 90 mm Hg.

B. 140-159/90-99 mm Hg.

C. 160-179/100-109 mm Hg.

D. ≥ 180/|≥ 110 mm Hg.

14. How is apex bit changed at patient with prolonged arterial hypertension?

A. Heaving displaced to the right, and resistant.

B. Heaving, displaced to the left, and not resistant.

C. Heaving, displaced to the left, and resistant.

D. Not changed, normal

E. Displaced to the right and not resistant.

15. How are the heart borders displaced at patient with the 1st stage of essential hypertension?

A. Shift to the right.

B. Shift to the left.

C. Shift to the left and up.

D. Shift to the right, left and up.

E. Not changed.

16. During auscultation of patients with hypertonic crisis you can hear:

A. Diminished S1 at the apex, and accented S2 at the aorta.

B. Loud S1 at the apex, and accented S2 at the aorta.

C. Increased S1 at the apex, and diminished S2 at the aorta.

D. Diminished S1 at the apex and S2 at the aorta.

E. Normal heart sounds

17. Which investigation is the most informative for establishing arterial hypertension?

A. Daily BP monitoring.

B. Daily EKG monitoring.

C. Coronarography.

D. Echocardiography

E. Tredmill test.

18. Criterions of the ІIІ stage of essential hypertension:

A. Episodic elevation of BP with cerebral, cardiac and general symptoms without any other signs except high BP.

B. Permanent symptoms and signs of the target organs affecting without their failure.

C. Permanent symptoms and signs of the target organs affecting with their failure (complicated stage)

D. Frequent hypertonic crisis.

E. Lack of effect of the medication treatment.

19. Which diseases can be accompanied with arterial hypertension?

A. Renal diseases

B. Endocrine disease

C. Coarctation of aorta.

D. Nephropathy of pregnancy

E. all mentioned above

20. EchoCG sign of the left ventricular hypertrophy:

A. Widening of the cavity of left ventricular.

B. Widening of the cavity of right ventricular.

C. Widening of the posterior wall of the left ventricle.

D. Widening of the left atrium cavity.

E. Low ejection fraction.

Control questions:

7. Definition, classification and risk factors of the arterial hypertension.

8. Symptoms and signs of arterial hypertension.

9. Data of additional methods of investigation at patients with arterial hypertension.

10. Definition and classification of the essential hypertension.

11. Complication of the uncontrolled arterial hypertension.

12. Main symptoms and signs of the hypertonic crisis.

Practical skills

1. Collecting symptoms at patient with arterial hypertension

2. Revealing signs of the arterial hypertension

3. Assessing data of ECG, Echocardiography and laboratory examination of the patient with arterial hypertension.