A 5\'6\", 210 pound, 64 year old man had a physical exam prior to his retirement

Question

A 5'6", 210 pound, 64 year old man had a physical exam prior to his retirement for corporate work. His blood pressure was greater than 180/115 mmHg on three separate days (normal blood pressure is 120/80). Further examination showed normal to low plasma renin activity, elevated peripheral resistance (PR), x-ray showed left ventricular hypertrophy and retinal hemorrhage and cardiac output was 7.2 L/min (normal is 3.5 to 5.5 L/min). Recommended therapy was weight reduction to his ideal weight, low salt diet. If these life style changes did not change his condition the following medication will be started in the following order: oral diuretics progress to beta blockers and then to a vasodilator.

1) What is the diagnosis for this individual?

2) Why is it suggested that the patient go on a low sodium diet?

3) Explain the site and mechanism of action of each of these prescribed medications. Include in your discussion how each of these medication would improve the patient’s condition (be very specific)

a) oral diuretic:

b) beta-blocker:

c) vasodilator:

d) angiotensin converting enzyme inhibitor

3) Define after load and preload, which one is increased in this patient; explain your answer

4) Define and indicate the cause of the ventricular hypertrophy?

5) What was the cause of the retinal hemorrhage?

Explanation / Answer

1.) As the patient is having blood pressure more than 180/115 mmHg; which is far more than normal blood pressure of 120/80 mmHg, he is diagnosed to be having hypertension.

2.) Sodium causes water retention which may lead to hypervolemia and which lead to increase in the blood pressure. So, the patient should restrict amount of salt in his diet.

3.)

a- Oral diuretics acts on the kidney at either loop of Henle or at the distal convoluted tubule based on the type of diuretic. The diuretic acts by decreasing the sodium water resorption and thus decreasing the volume of blood and maintaining the work load on heart.

b- Beta blocker acts on the beta receptors on the heart muscle and decrease the heart rate.

c- Vasodilator like an alpha 1 blocker acts on the smooth muscle of the blood vessel and leads to the vasodilation which may be responsible for the peripheral pooling of the blood and thus decreasing the volume over load on the heart.

d- Angiotensin converting enzyme inhibitor inhibits the angiotensin converting enzyme which is essential in renin angiotensin aldosterone mechanism.

3) After load and preload:

            The amount of resistance/pressure against which the heart must work to open the aortic valve and eject blood into systemic circulation during systole is known as Afterload.

Preload is the volume of blood that is present after the end of diastole. In other words, the amount of blood that could be accommodated by the ventricles when they expand to their maximum extant.

The patient is diagnosed to have elevated peripheral resistance (PR); which means the resistance offered by the systemic circulation, when heart tries to push blood into systemic circulatory system. So, the afterload has increased in the patient.

4.) Thickening of the walls of ventricles is known as ventricular hypertrophy. It could be either due to volume-overload or pressure-overload. The walls of ventricles thicken in response to the increasing blood demand or pressure built-up. This leads to severe hypertension.

5.) Blood bleeding from delicate/sensitive tissue on the back wall of an eye is referred as retinal hemorrhage. Major cause for retinal hemorrhage is hypertension. Increased blood pressure in the veinlets/capillaries forces blood to leak-out at possible sensitive areas of tissue. Being sensitive, the back wall of eye becomes a site for the leak-out of blood, which is termed as retinal hemorrhage.

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