MINISTRY OF HEALTH OF UKRAINE

IVANO – FRANKIVSK NATIONAL MEDICAL

UNIVERSITY
Internal Medicine Department

CASE HISTORY

Student’s name and surname- SATYAJIT MOHANTY

Faculty- MEDICINE
Course____IV_______group___59E+__
Teacher’s name and surname- Галина Миколаївна Курилів

Ivano-Frankivsk 2023
 I. PASSPORT DATA
Name and surname of the patient-SANGAM RAJ
Age -50YRS
Sex -MALE
Education – HIGH SCHOOL FOOTBALL COACH
Address-BHOPAL,INDIA
Work place, occupation -BHOPAL, Head in Tata Consultancy Services
Date of hospitalization-1April 2023
Final diagnosis=Based on objective and subjective parameters the patient is
suffered with Stage 2 Arterial Hypertension

PATIENT’S COMPLAINTS
The patient was a 50-year-old male who was admitted to our hospital in April
2023 due to
uncontrolled hypertension for 6 months and weakness of limbs for 20 days.
Six months prior to admission, blood pressure of the patient was found to
 have increased to 200/120 mmHg during the physical examination. Since
then, his blood pressure fluctuated between 180-200/100-120 mmHg.
The patient did not present obvious symptoms like headache, dizziness,
palpitation, arrhythmia, or
hyperhidrosis. He bought some antihypertensive drugs (with unknown
names, including diuretics)
and kept his blood pressure at around 160/100 mmHg.
Twenty days ago, he was admitted to a local hospital due to limb weakness
without other symptoms.

ANAMNESIS OF THE DISEASE

Overall general condition of the patient was fair and limb weakness
without other symptoms. There was no history of allergy to drugs,
chemicals and food substances.
Now he is hospitalised on April 2023.

ANAMNESIS OF LIFE
Walks 30mins,4-5 times per week
Previously a 2- pack a day smoker

GENERAL OBJECTIVE CONDITION OF THE PATIENT

Height-6 feet 3 inches

Weight-220 lbs.
BP= 160/100 mm of hg
Blood potassium= 2.51 mmol/L
Medical History=Stage 2 Arterial Hypertension
Previous pharmacological Treatment=25g Hydrochlorothiazide OD ,
dexamethasone 9 mg orally per day.

CVS

 Patient physical examination showed the following:

blood pressure: Left upper limb 163/82 mmHg, left lower limb
108/79 mmHg, right upper limb 176/86 mmHg, and right lower
 limb 114/80 mmHg.

 Ankle Brachial index (ABI) was 0.65 on the

right side and 0.66 on the left.

 No murmur was heard in the carotid

artery, and no enlargement of the thyroid gland was detected.
 Upon auscultation, II/VI systolic ejection murmur on the left upper
sternal border was heard.

 Bilateral femoral artery pulsation was weakened.

 No abnormalities were found in the rest physical examination.

Musculoskeletal system- Arthralgia’s present

Kidney examination: An extensive workup for full blood count, urine test,
urea, liver function, thyroid function, systemic immunity tests, and electrolyte
levels were normal.

Scalp: Normal

Nails: Nail clubbing

Oral mucosa: Xerostomia (dry mouth) and gingival overgrowth
The nervous system- the pathology of the nervous system was not found.

Endocrine system: Excess production of mineralocorticoids (i.e. primary

hyperaldosteronism)

DESRIPTION OF LOCUS MORBI

Six months prior to admission, blood pressure of the patient was found to
have increased to 200/120 mmHg, during the physical examination. Since
then, his blood pressure fluctuated between 180-200/100-120 mmHg.
The patient did not present obvious symptoms like headache, dizziness,
palpitation, arrhythmia, or hyperhidrosis.
RESULTS OF LABORATORY OR SPECIAL TESTS ( X-RAY, BIOPSY,
CULTURAL EXAMINATION, MICROSCOPIC EXAMINATION, ETC. )
*Echocardiography showed left ventricular hypertrophy,
*aortic regurgitation (mild), and
*tricuspid regurgitation (mild).
*Urinary cortisol: 31.62 ;normal: 21 μg/24 h to
110 μg/24 h),
*urinary Vanillylmandelic Acid (VMA): 6.2mg
(normal:<13.6 mg/24 h),
* blood catecholamine's, and metabolites were normal.
*The patient stopped taking the original antihypertensive drugs.
*Bilateral carotid artery ultrasound was normal.
*Adrenal and renal artery Computed tomography angiography: No
abnormalities were observed in bilateral adrenal glands, and no renal artery
stenosis was observed.

DIFFERENTIAL DIAGNOSIS
Hyperaldosteronism, coarctation of the aorta, renal artery stenosis,
chronic kidney disease, and aortic valve disease.

FINAL DIAGNOSIS

Based on objective and subjective parameters the patient is suffered with

2 degree Arterial Hypertension due to overdose of nicotine through
nd

smoking.

ETIOLOGY AND PATHOGENESIS OF THE DISEASE

 Most cases of hypertension are idiopathic which is also known as
essential hypertension. It has long been suggested that an
increase in salt intake increases the risk of developing
hypertension.
 One of the described factors for the development of essential
hypertension is the patient genetic ability to salt response. About
 50 to 60% of the patients are salt sensitive and therefore tend to
develop hypertension.
 Secondary hypertension develops as a consequence of other
diseases or due to chemical substance like Nicotine or medicine.
 The causes of secondary hypertension vary with age. The
etiologic factors of secondary hypertension in adolescents mostly
include renal parenchymal disease, CoA, and monogenic
disorders.
 This work covers a patient with CoA who presented typical signs
with severe hypertension diagnosed as CTA of the thoracic aorta.
 His typical signs included upper limb blood pressure higher than
lower limb blood pressure, coarse vascular murmurs audible in
the chest, and weakened femoral artery pulsation.
 This case gives us a most important warning, reminding us to
screen for CoA in adolescents with typical signs.

TREATMENT AND PREVENTION OF THE DISEASE

 We performed full-exon gene testing using high-throughput
sequencing, but found no clear pathogenicity variants associated
with disease phenotypes.
 He was then transferred to our cardiac surgery department for
aortic stent implantation , and he did well after the operation.
 To control blood pressure of patient I prescribed:
 Amlodipine 5 mg orally once a day
 Losartan 50 mg orally once a day
 Lisinopril 10 mg orally once a day
 For Arthralgia: Celecoxib 200mg twice a day per orally.
 For primary hyperaldosteronism : Spironolactone 25mg/day PO

PREVENTION
 Patient education is paramount to effective management and should
always include detailed instructions regarding weight management, salt
restriction, smoking management, adequate management of obstructive
sleep apnea and exercise.
 Patients need to be informed and revised at every encounter that these
changes are to be continued lifelong for effective disease treatment.
  Weight reduction is advisable if obesity is present although optimum
BMI and optimal weight range is still unknown. Weight reduction
alone can result in decreases of up to 5 to 20mmHg in systolic blood
pressure.

 Smoking may not have a direct effect on blood pressure but will help in
reducing long term sequelae if the patient quits smoking.

 Lifestyle changes alone can account for up to 15% reduction in all

cardiovascular-related events.

REHABILITATION AND PROPHYLAXIS

 Eating a heart-healthy diet with less salt.
 Getting regular physical activity.
 Maintaining a healthy weight or losing weight.
 Limiting alcohol.
 Not smoking.
 Getting 7 to 9 hours of sleep daily.

PROGNOSIS FOR THE PATIENT

Large scale metanalyses have also shown the rising Cardiovascular
disease and vascular disease risk with a rise in systolic and
diastolic blood pressures, with almost doubling of risk of death
from heart disease and stroke with rising SBP of as much as 20 and
DBP of 10mmHg.

The prognosis depends on blood pressure control and is favorable

only if the blood pressures attain adequate control; however,
complications may develop in some patients as hypertension is a
progressive disease.

Adequate control and lifestyle measures only serve to delay the

development and progression of sequelae such as chronic kidney
disease and renal failure.

EPICRISIS
 Secondary hypertension is more harmful than primary
hypertension.
 Early identification and early treatment are particularly
 important.
 Drug induced hypertension or due to overdose of nicotine is an
extremely important cause of secondary hypertension in
adolescents.
 Screening the causes of hypertension according to the
characteristic symptoms and signs can reduce the patient’s
economic burden, shorten the diagnosis and treatment time,and
offer the patient more benefits.