case study

Palestinian Territory

#1 Mar 15, 2011
-Day1 Mr Y, a 58-year-old man , was admitted to hospital complaining of left-sided weakness following stroke.
His previous medical history was unmarkable. He did not smoke and drank only socially. He had not been taking any drugs prior to admission.
He was obese (weight 95kg)and on examination was found to be hypertensive (resting blood pressure BP 170/120 mmHg with pulse rate of 72 beats/min.
He was prescribed ( thiazide) bendrfluazide 5mg in the morning
, and put on a weight-reducing diet. Regular physiotherapy was started to improve movement in his arm and leg.
His serum biochemistry and hematology results were:
Na 139 mmol/L (135-148)
K 4.2 mmole / L (3.5-5)
Urea 5.6 mmole/L ( 2.9-7)
Hemoglobin 14.1 g/dl (12-18)
One week later Mr Y 's BP was still raised (165/ 115mm Hg), and his dose of thiazide was increased to 10mg daily.
After a further six days his hypertension was unchanged, so
(-blocker) atenolol 50mg in the mornibg was addedto his drug therapy.
Q1- What are the aims of treating hypertension and how can they be achieved?
Q2- Was the treatment prescribed for Mr Y appropriate?
Q3- How should thiazide and - blocker therapy be monitored?
- Day 28 Mr Y's BP was controlled at 135/85 mmHg.
However , routine urine analysis showed traces of sugar, but no protein or ketones.
Q4- Why might Mr Y have sugar in his urine?
Q5- What action would you have recommended?
The team treating Mr. Y decided to stop the thiazide and increase the dose of atenolol to 100 mg in the morning.
A random blood glucose measurement was:
11.2 mmol/L (3.9- 10) and his serum K was 3.9 mmol/L (3.5-5)
-Day 42 Mr. Y's mobility had improved sufficiently to allow him to go home.
His blood sugar was normal and his BP was 130/90 mmHg.
He was discharged on atenolol 100mg daily.
-Month 8 Mr. Y attended a routine out-patient appointment . He claimed he was still taking atenolol 100mg daily, but his BP was 160/120 mmHg.
It was decided to add prazocin to his regimen, starting with a dose of 500 micrograms at bedtime,
then 500 micrograms twice daily.
He was asked to return to the clinic at weekly intervals, so that the dose of prazocin could be adjusted according to his BP.
He was eventually established on atenolol 100mg daily and prazocin 1 mg three times daily.
Q6- Was the dose regimen of prazocin appropriate ?How should the dose be increased and was increments?
Q7- Would you have recommended prazocin? What other vasodilators could have been used?

Palestinian Territory

#2 Mar 15, 2011
-Month 56 over the last four years, Mr.Y had remained well on the same drug therapy, but at a routine out-patient visit,
he was found to be hypertensive ( BP 175/120 mmHg).

He was complaining of tired leg ; on further questioning , he admitted he had not been taking his tablets recently as he had run out of them and they weren't doing me any good, and it is difficult to remember to take them three times a day.

The prazocin was stopped and nifidipine 20 mg tablets twice daily added to the atenolol. Mr Y was counseled by the clinic doctor regarding the importance of his drug therapy.

Q8- What are the difference of calcium-channel blockers used for hypertension? Which you have recommended for Mr.Y ?

-Month 58 , Mr. Y returned to out-patients complaining of headaches and lightheadedness.

His BP was 150/ 95 mmHg and it was decided to admit Mr.Y for review and rationalization of his antihypertensive therapy.

His serum biochemistry and hematology results were:
Na 138mmol/L ( 135- 148)
K 3.9 mmol/L(3.5-5)
Urea 7.1 mmol/ L ( 2.9-7.0)
Glucose 6.0 mmol/L(3.9 -10.0)
Hemoglobin 14.5 g/dL (12-18)

The medical team decided to use ACE- inhibitor.

Q10- What appear to be advantages of ACE-inhibitors in the treatment of hypertension?

Q11- Would you recommend any adjustments to his existing therapy?

Q12- Would parameters would you want to monitor whilst Mr. Y is receiving an ACE-inhibitor?

It was decided to start aspirin 75mg daily to prevent a further stroke , as Mr.Y had had a transient ischemic attack on the second day of the admission.

Mr. Y's was eventually controlled on atenolol 100mg once daily and enalopril 10mg in the morning.

Q13- What points would you cover when counseling Mr. Y on discharge?

jamal omar

Palestinian Territory

#3 Mar 16, 2011
na3eema ya abu fayez

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