Common abnormalities

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Hypertension. Systemic hypertension is common, particularly in the elderly, has no specific symptoms but, if untreated, can lead to death or morbidity from heart disease, cerebrovascular accident or renal failure. Clinical assessment of the hypertensive patient has three aims:

• to seek a specific cause

• to assess the severity of the problem

• to evaluate the extent of damage already done and the overall risk of cardiovascular disease (Fig. 3. S 8).

The secondary causes of hypertension arc all relatively rare but are more likely in younger subjects. Many patients with essential, or primary, hypertension give a family history of the condition. However, the diagnosis is one of exclusion. Other specific questions to ask include a detailed renal history because renal disease is the commonest secondary cause of hypertension. A history of paroxysmal headaches, vomiting, sweating, pallor and weight loss, may suggest phaeochromocytoma. Enquiry should also be made concerning alcohol intake; some secondary causes, e.g. Conn's syndrome, have no specific symptoms.

The severity of the hypertension will influence the need for treatment, This will involve asking questions about cardiac symptoms, particularly dyspnoea and angina, and making an overall assessment of the cardiovascular risk taking into account the patient's age. sex. smoking habit, and family history.

The choice of treatment will also be influenced by the presence or absence of complications. For example beta-blocking agents and calcium channel antagonists may be particularly useful in treating hypertensives with angina but an ACE inhibitor with a diuretic may be preferred if there is significant left ventricular dysfunction.

Examination sequence

□ Make serial recordings of the blond pressure.

□ Check the pulse for atrial fibrillation.

□ Look for radiofemoral delay in patients <40 years old.

□ Examine the optic fundi for hypertensive retinopathy (p. 256-257).

□ Look for features of Cushing's syndrome (Fig. 2.8A and p. 32) or virilisation.

□ Palpate the abdomen for adrenal masses and for enlarged kidneys (p. 165).

□ Auscultate for bruits over the renal arteries.

□ Examine the heart for features of left ventricular hypertrophy (p. 91).

□ Look for evidence of cardiac failure (p. 101).

□ Perform microscopic examination of the urine

(p. 180-1 81) looking particularly for red ccll casts (Fig. 5.27).

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