Case of the GP under Pressure

Question 1

high blood pressure affects people in UK?

Answer 1

1 in 4

Question 2

hypertension is?

Answer 2

3 rd biggest risk factor

Question 3

every 10mmHg reduction in BP reduces?

Answer 3

CAd- 17%
Stroke- 27%
HF-28%
all cause mortality- 13%

Question 4

Blood pressure equation

Answer 4

BP=CO x PR

Question 5

cardiac output equation?

Answer 5

CO= HR x SV

Question 6

pathogenesis of HTN?

Answer 6

increased sympathetic tone
increased peripheral vascular resistance
RAAS activation
Increased cardiac output

Question 7

causes of HTN?

Answer 7

primary-90%
secondary- 10% underlying disease
younger patients, hypertensive crises, abnormal blood results, signs and symptoms

Question 8

Causes of HTN?

Answer 8

PKD, glomerulonephritis, renal artery stenosis
High aldosterone, cushings, phaechromocytoma, hypo/hyperthyroidism, hyperparathyroidism, acromegaly

Steroids, COCP, NSAIDs, cocaine, antidepressant, EPO,

obstructive sleep apnoea

pregnancy

congenital-coarction of the aorta

Question 9

risk factors of HTN?

Answer 9

male, age, FH, ethnicity (south asian, black african), smoke, high lipids, diabetes, socioeconomic status

Question 10

RAAS?

Answer 10

Renin from juxtaglomerular apparatus released and will act on angiontensinogen released from liver. this will produce angiotensun 1, which is converted angiotensin II by ACE enzyme.

angiotensin II increases sympathetic activity, aldosterone secretion, tubular Na/Cl absorption and K excretion, H20 retention, arteriolar vasoconstriction, ADH secretion-H2O reabsorption

Question 11

hyperaldosteronism?

Answer 11

low plasma renin
40%- Conns
bilateral adrenal hyperplasia- 60%

Question 12

key investigation for hyperaldosteronism?

Answer 12

high plasma aldosterone/ renin ratio

Question 13

pH in hyperaldosteronism?

Answer 13

metabolic alkalosis

Question 14

how to check for what type of hyperaldosteronism?

Answer 14

CT/MRI adrenals

Adrenal vein sampling- lesion is functional

Question 15

how to treat hyperaldosteronism?

Answer 15

laparoscopic adrenalectomy

radiofrequency ablation

mineralocorticoid receptor antagonist- spironolactone/eplerinone

Question 16

causes of hyperaldosteronism with high plasma renin?

Answer 16

secondary hyperaldosteronism- kidneys detect low kidney blood flow

renal artery stenosis

coarction of the aorta

reninoma
hereditary disorders

Question 17

diagnosis of high plasma renin hyperaldosteronism?

Answer 17

HTN
low plasma aldosterone: renin ratio
high creatinine
MR renal angiogram
CT renal angiogram/ renal dopplers

Question 18

gold standard of high renin aldosterinism?

Answer 18

renal angiogram

Question 19

10% of renal artery stenosis?

Answer 19

fibromuscular dysplasia- beading

Question 20

treatment high renin hyperaldosteronism?

Answer 20

medical- control BP
renal angioplasty
stent insertion
surgical repaire

Question 21

ateriosclerosis?

Answer 21

blood vessels become thicker

Question 22

atherosclerosis?

Answer 22

inflammatory process and high cholesterol leading to plaque, which could narrow the artery

Question 23

how to diagnose target organ damage?

Answer 23

fundoscopy for retinopathy
ECG- LVH, AF
Urinalysis- proteinuria
Bloods- U/Es

Question 24

acute target organ damage due to hypertensive crisis?

Answer 24

eyes- retinal haemorrhage/ papilloedema
brain-encephalopathy, stroke
heart- pulmonary oedema, MI
Kidneys- AKI
aortic dissection
pre-eclampsia

Question 25

causes of secondary hypertension CHAPS?

Answer 25

Cushings Hyperaldosteronism Aortic Coarctation Pheochromocytoma Stenosis of renal arteries

Question 26

phaechromocytoma?

Answer 26

adrenal medullary tumour that secretes excess catecholamines from chromaffin cells

Question 27

paraganglioma?

Answer 27

neuroendocrine tumours that arise from sympathetic and parasympathetic ganglia

Question 28

common signs and symmptoms of phaechromocytoma/paraganglioma?

Answer 28

headache sweating high blood pressure tachycardia anxiety palpitation abdominal pain dizziness blurry vision diabetes symptoms Heart failure

Question 29

phaechromocytoma affects

Answer 29

0.01 to 0.1%

Question 30

investigate phaechromocytoma if?

Answer 30

signs/ symptoms severe HTN, HTN crisis refractory HTN>3 drugs HTN at young age adrenal lesion FH

Question 31

phaechromocytoma 5 Ps?

Answer 31

pain pressure palpitation perspiration pallor paroxysms spells

Question 32

mechanism of hypotension in phaechromocytoma?

Answer 32

loss of postural reflexes due to prolonged catecholamine stimulation release of adrenomedullin (vasodilatory neuropeptide)

Question 33

catecholamines cause?

Answer 33

dilated cardiomyopathy so affect systolic dysfunction

Question 34

HTN causes?

Answer 34

hypertrophic cardiomyopathy so affects systolic function

Question 35

other features of phaechromocytoma?

Answer 35

lipolysis mild glucose intolerance hypercalcaemia- MEN2, PTHrP secreted by pheo

Question 36

adrenaline is produced in?

Answer 36

only adrenals because phenyethanolamine n-methyltransferase is present only there

Question 37

if clinical suspicion of PPGL first check?

Answer 37

urine metanephrines then imaging

Question 38

why might you get a false positive for high metanephrines in urine?

Answer 38

extreme stress, critical illness, non supine position, sympathoadrenergic activity, renal insufficiency, diet (coffee, tea, bananas, chocolate), medication

Question 39

what is a really good scan for phaechromocytoma?

Answer 39

galium dotatate

Question 40

preoperative treatment?

Answer 40

7-14 days alpha adrenergic receptor blocker- phenoxybenzamine, doxazocin propanolo- if tachycardic calcium channel blocker metyrosine- sympathtic

Question 41

familial phaechomoctoma?

Answer 41

40%- bilateral, paragnaglioma, unilateral with FH, uinlateral and young age of onset, metastasis

Question 42

familial phaechromocytoma could be due to?

Answer 42

MEN 2a, MEN 2b, Von Hippel-landau, NF1, familial paraganglioma, familial pheo and islet cell tumout

Question 43

men 2 a?

Answer 43

pheochromocytoma, medullary thyroid carcinoma, parathyroid hyperplasia

Question 44

men 2b?

Answer 44

pheochromocytoma, medullary throid carcinoma, marfanoid habitus, mucosal neuroma

Question 45

NF1?

Answer 45

cafe au lait spots, neurofibroma and optic glioma

Question 46

von hipple landau?

Answer 46

pheochromocytoma, retinoblastoma, cerebellar hemangioma, nephroma, renal/pancreas cysts

Question 47

familial pheochromocytoma gene

Answer 47

succinate dehydrogenase mutation

Question 48

WHO healthcare quality dimensions?

Answer 48

effective- adherent to an evidence base and results in improved health outcomes efficient- maximises resource use and avoids waste accessible acceptable- takes into account preferences and aspirations of individual service users/ cultures of their community equitable- safe

Question 49

sustainability?

Answer 49

outcome for patients and populations divided by environmental social and financial impacts

Question 50

components of healthcare (donabedian model)?

Answer 50

structure- facilities, equipment, human resources, process- care seeking behaviour, diagnosis, treatment outcome- patient knowledge, behaviour, health status and satisfaction

Question 51

audit?

Answer 51

way to find out if healthcare is being provided in line with standards and let care providers and patients know where their service is doing well and where there could be improvements

Question 52

stimulus for quality improvement?

Answer 52

reflective case, large scale data, feedback, learning event analysis

Question 53

research?

Answer 53

creating new knowledge that can be generalised beyond the participant sample or setting

Question 54

difference in clinical audit vs quality improvement?

Answer 54

audit- evaluating service against a benchmark QI- find out something about that service which can be used to improve that service

Question 55

which cycle is pertinent to improvent?

Answer 55

plan do study act