HTN Complications

1. A 55-year-old runner presents to the clinic complaining of exertional dyspnea, general fatigue and severe lightheadedness. He was diagnosed with hypertension (HTN) 20 years ago and is on hydrochlorothiazide (HCTZ) and enalapril. On physical examination, you find his blood pressure (BP) to be 145/90 mmHg and heart rate (HR) 50/min. His point of maximal impulse (PMI) is detected at the sixth intercostal space on the anterior axillary line. The electrocardiogram (ECG) shows sinus-bradycardia and a right bundle branch block (RBBB) pattern. Based on the above findings, which of the following is the most likely cause behind his condition?

2. Regarding the previous medical case, which of the following is the best non-invasive diagnostic modality to evaluate the presence of any myocardial changes?

3. A 60-year-old female presents to the emergency room with a one-month history of occasional severe headaches, blurry vision, and dizziness. Her past medical history is significant for hypertension (HTN) controlled by Co-divan a combination of a thiazide diuretic and the angiotensin receptor blocker (ARB) valsartan and chronic obstructive pulmonary disease (COPD) which she rarely takes medications for. Her family history is significant for HTN and diabetes. She smokes daily but never drinks alcohol. Her blood pressure (BP) is 210/145 mmHg and heart rate (HR) is 70/min. On physical examination, retinal hemorrhage is present. Which of the following is the most consistent with the diagnosis of malignant hypertension in this patient?

4. Regarding the previous clinical case, which of the following is the most likely morphologic change associated with this patient’s condition?

5. Regarding the previous clinical case, which of the following is the indicated drug if she develops an exacerbation of her chronic obstructive pulmonary disease (COPD)?

6. A 60-year-old male presents to the emergency room with sudden, severe headache accompanied by vomiting and altered consciousness. His past medical history is significant for long-standing hypertension (HTN) and diabetes. A CT-scan of the head was performed, which showed mild atrophy with no acute bleeding. During the first 24 hours after this episode, which of the following is the threshold level for starting treatment to control his blood pressure (BP)?

7. Regarding the previous clinical case, the patient presents with right-sided hemiparesis a few years later. On physical examination, his blood pressure (BP) is 225/133 mmHg. CT-scan of the head shows no acute bleeding. An electrocardiogram (ECG) reveals left-ventricular hypertrophy (LVH). Which of the following is the most therapeutic goal for his BP?

8. A 52-year-old male presents for evaluation of his blood pressure (BP). He has no complaints or any significant past medical history. On physical examination, his BP is 220/130 mmHg. The rest of his physical examination, laboratory values, and electrocardiogram (ECG) results are normal. Which of the following is the most effective management at this time?

9. Which of the following patients would most likely be suffering from secondary hypertension?

10. A 40-year-old male, known case of hypertension (HTN), presents to the clinic for routine evaluation. His blood pressure (BP) is well-controlled with hydrochlorothiazide (HCTZ). His BP at this visit is 120/79 mmHg. Laboratory evaluation shows a serum creatinine (Cr) level of 1.1mg/dL (normal) and his glomerular filtration rate (GFR) is greater than 90mL/min. Microalbuminuria is detected on urinalysis. Which of the following is the most appropriate step of management in this patient?

11. Regarding the previous clinical case, the patient is also prescribed lisinopril 20mg daily along with his diuretic. He comes back two weeks later for a follow-up appointment and routine evaluation. On blood work-up, his serum creatinine (Cr) level has increased from 1.1 to 1.35 mg/dL (normal range 0.6-1.2 mg/dL). His blood pressure (BP) at this visit is 115/78 mmHg. Which of the following is the most appropriate step of management at this time?

12. Regarding the previous clinical case, which of the following is the target blood pressure (BP) in hypertensive (HTN) patients with chronic renal insufficiency?

13. Regarding the previous clinical case, the patient presents for a follow-up visit and routine evaluation a week later. On physical examination, his blood pressure (BP) at this visit is 138/85 mmHg. Blood samples were sent to the lab for investigation and the following results stood out:
• Serum creatinine (Cr) level is 1.7 mg/dL.
• Estimated glomerular filtration rate (eGFR) is 80 mL/min.
Based on the above findings, which of the following is the most appropriate step of management at this time?

14. Regarding the previous clinical case, the patient presents for a routine evaluation two weeks later with normal serum markers and a controlled blood pressure (BP). He was given another follow-up appointment a month later which he skipped. He presents a year later with a BP of 148/85 mmHg. He states that he is still on his current medical regimen of lisinopril 40mg/day and hydrochlorothiazide (HCTZ) 25mg/day. Blood samples were sent to the lab to reveal a serum creatinine (Cr) of 2.1mg/dL and an estimated glomerular filtration rate (eGFR) of 39mL/min. Based on these new findings, which of the following is the most appropriate step of management at this time?

15. Regarding the previous clinical case, the patient presents a few years later with a four-day history of headaches, nausea, and vomiting. He reports seeing spots and experiencing periods of mental confusion. His blood pressure (BP) at this visit is 260/155 mmHg. Laboratory test reveals a serum creatinine (Cr) level of 2.5 mg/dL, and a blood urea nitrogen (BUN) level of 47mg/dL. Urinalysis shows mild proteinuria and moderate hematuria. Several weeks later, he dies from cerebral bleeding. A kidney autopsy is obtained. Which of the following histologic changes would most likely be seen on biopsy?