Sandra Smith

Sandra Smith

1. Key Information

   • 46 years old
   • Went to the GP for a routine smear test
     • Results looked healthy
     • Last one was 3 years ago
   • Anxious to go to the GP
   • BMI of 31.2
   • High blood pressure
   • Waist:Hip ratio is 1.02
     • High risk of CVD
   • Heart rate is normal at 70 beats/min
   • No heart murmurs or thrills
   • History
     • No chest pain, shortness of breath, cough, wheeze, fainting, headaches or vision issues
     • 3 children (10, 15 and 17)
     • IUD contraceptive device
     • Antibiotics for UTI
     • Father died of a stroke and brother has high blood pressure
   • Lifestyle
     • Smokes
     • Drinks 12 units of alcohol per week
       • Gin and Tonic most evenings
     • Not active
     • Eats takeaways and convenience food
     • Stressed

2. Blood Pressure

   • Blood pressure is the force of the blood pushing against the artery walls
     • The force is generated with each heartbeat as blood is pumped into the blood vessels
       • Each time the heart beats, pressure is created inside the arteries
     • The size and elasticity of the artery walls also affect blood pressure
     • The pressure is greatest when blood is pumped out of the heart into the arteries and the pressure falls when the heart relaxes
   • Control Mechanisms
     • The cardiovascular center provides a rapid, neural mechanism for the regulation of blood pressure by managing cardiac output or by adjusting blood vessel diameter and is located in the medulla oblongata of the brain stem
       • Sensors
         • Baroreceptors are sensory neurons that monitor arterial blood pressure
           • Major baroreceptors are located in the carotid sinus, the aortic arch, and the right atrium
         • Chemoreceptors are sensory neurons that monitor levels of CO2 and O2
     • The renin‐angiotensin‐aldosterone system of the kidneys regulates blood volume
       • In response to rising blood pressure, the juxtaglomerular cells in the kidneys secrete renin into the blood
         • Renin converts the plasma protein angiotensinogen to angiotensin I, which in turn is converted to angiotensin II by enzymes from the lungs
           • Angiotensin II activates two mechanisms that raise blood pressure
             • Angiotensin II constricts blood vessels throughout the body (raising blood pressure by increasing resistance to blood flow)
               • Constricted blood vessels reduce the amount of blood delivered to the kidneys, which decreases the kidneys' potential to excrete water (raising blood pressure by increasing blood volume)
             • Angiotensin II stimulates the adrenal cortex to secrete aldosterone, a hormone that reduces urine output by increasing retention of H2O and Na+ by the kidneys (raising blood pressure by increasing blood volume)
     • Hormones and other substances
       • Epinephrine and norepinephrine, hormones secreted by the adrenal medulla, raise blood pressure by increasing heart rate and the contractility of the heart muscles and by causing vasoconstriction of arteries and veins
       • Antidiuretic hormone (ADH), a hormone produced by the hypothalamus and released by the posterior pituitary, raises blood pressure by stimulating the kidneys to retain H2O
       • Atrial natriuretic peptide (ANP), a hormone secreted by the atria of the heart, lowers blood pressure by causing vasodilation and by stimulating the kidneys to excrete more water and Na +
       • Nitric oxide (NO), secreted by endothelial cells, causes vasodilation
       • Nicotine in tobacco raises blood pressure by stimulating sympathetic neurons to increase vasoconstriction and by stimulating the adrenal medulla to increase secretion of epinephrine and norepinephrine
       • Alcohol lowers blood pressure by inhibiting the vasomotor center (causing vasodilation) and by inhibiting the release of ADH
   • Sandra's readings were repeated when she had been relaxed for at least 5 mins
     • The repeat BP readings are 159/96 and 157/95 mmHg

3. Hypertension

   • Prevalence
     • Approximately 1 in 4 adults worldwide have high blood pressure
     • High blood pressure affects more than 1 in 4 adults in England, around 12.5 million people in 2015
       • In England 31% of men and 26% of women have high blood pressure
   • Differences in blood pressure
     • Age
       • In the UK, as in other developed nations, blood pressure tends to rise with age
         • This is thought to reflect the length of time that people are exposed to modifiable lifestyle risk factors
     • Gender
       • Health Survey for England figures show that for any given age up to about 65 years, women tend to have a lower blood pressure than men
         • Between 65 to 74 years of age, women tend to have a higher blood pressure
     • Ethnicity
       • In England, people from Black African and Black Caribbean ethnic groups have a higher risk of hypertension than the general population, although any differences in hypertension between other ethnic groups is not always apparent
         • Ethnic groups, such as South Asian, Black African and Black Caribbean communities, are more prone to developing type 2 diabetes which also increases the risk of having high blood pressure
     • Genetics may also be a factor in hypertension
   • Types of hypertension
     • 90% of hypertension is essential where there is no known secondary cause
       • The remaining 10% is secondary where there is another medical condition causing the hypertension
   • What happens if hypertension is left untreated
     • Heart attack
       • High blood pressure damages arteries that can become blocked and prevent blood flow to the heart muscle
     • Stroke
       • High blood pressure can cause blood vessels in the brain to clog more easily or even burst
     • Heart Faliure
       • The increased workload from high blood pressure can cause the heart to enlarge and fail to supply blood to the body
     • Kidney disease or faliure
       • High blood pressure can damage the arteries around the kidneys and interfere with their ability to filter blood effectively
     • Vision loss
       • High blood pressure can strain or damage blood vessels in the eyes
     • Peripheral artery disease
       • Atherosclerosis caused by high blood pressure can cause a narrowing of arteries in the legs, arms, stomach and head, causing pain or fatigue
     • Sexual dysfunction
       • High blood pressure can lead to erectile dysfunction in men or lower libido in women

4. Anti Hypertensive Medication

   • Diuretics
     • Diuretics help the body get rid of excess sodium (salt) and water and help control blood pressure
     • They are often used in combination with additional prescription therapies
     • The main types of diuretics are thiazide diuretics, potassium- sparing diuretics, loop diuretics and combination diuretics
   • Beta Blockers
     • Beta-blockers reduce the heart rate, the heart's workload and the heart's output of blood, which lowers blood pressure by reducing the sympathetic innervation
       • Beta blockers may be used by them self or in combination with a diuretic
   • ACE inhibitors
     • ACE inhibitors help the body produce less angiotensin, which helps the blood vessels relax and open up, which, in turn, lowers blood pressure
       • Also makes the body retain less water and Na+, increasing urine excretion and reducing blood volume
   • Angiotensin receptor blockers
     • These drugs block the effects of angiotensin by blocking their receptors and then it will not be able to constrict the blood vessel and blood pressure is reduced
   • Calcium channel blockers
     • This drug prevents calcium from entering the smooth muscle cells of the heart and arteries and help to relax and open up narrowed blood vessels, reduce heart rate and lower blood pressure
   • Alpha Blockers
     • These drugs reduce the arteries' resistance, relaxing the muscle tone of the vascular walls
   • Alpha 2 Receptor Agonists
     • These drugs reduce blood pressure by decreasing the activity of the sympathetic nervous system
       • Methyldopa is considered a first line antihypertensive during pregnancy because adverse effects are infrequent for the pregnant woman or the developing fetus
   • Combined alpha and beta blockers
     • Combined alpha and beta-blockers are used as an IV drip for those patients experiencing a hypertensive crisis
       • They may be prescribed for outpatient high blood pressure use if the patient is at risk for heart failure

5. Symptoms of Anxiety

   • Sweating
     • The sympathetic nervous system can stimulate the hypothalamus in times of stress to promote sweating
       • Release of Ach acting at Mus receptors (not NA, exception to the normal rule) induces sweating for temperature control during the ‘’fear-fight-flight’’ response
   • Most of the symptoms of anxiety are triggered by the sympathetic nervous system in response to stress
   • Heart Palpatations
     • Noradrenaline and adrenaline act at ꞵ1- adrenoceptors in the heart
     • SA Node
       • Increases frequency of pacemaker potentials which produces an increase in heart rate
         • Chronotropic effect
     • Conduction system
       • Increases rate of impulses through the atria to ventricles to maintain balance between heart rate and contractions
         • Dromotropic effect
     • Cardiac Muscle
       • Increases force of contraction of atria and ventricles
   • Tingling and numbness
     • Anxiety can cause hyperventillation, even if you don't realise your breathing has changed
       • This causes respiratory loss of carbon dioxide which is the primary acid in the blood
         • This deficiency leads to respiratory alkalosis and in turn to ionization of some elements, including calcium and potassium
           • Hypocalcemia and hypokalemia are responsible for the tingling sensations in the mouth, hands and feet that often occur in anxious people

6. Investigations

   • Blood Test Results
     • High Values
       • Cholesterol
       • Triglycerides
       • LDL
       • Glucose
         • May be diabetic but a repeat is needed to confirm whether she is or not
     • Low HDL levels
   • Urine Analysis
     • High Na+ excretion in 24 hours
       • Due to high salt content in diet
   • Heart
     • ECG shows a left ventricular hypertrophy
       • Due to the heart working harder for a long time because of her hypertension
         • Can be reversed if blood pressure is reduced and stays at the new level
     • Echocardiogram shows a thickened left ventricle

Bilder und Dateien der Mindmap