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  1. #1
    Statia Graduate is offline Junior Member 510 points
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    A bit of a tough one

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    Read this one carefully!

    83 year old AAM with HTN, HLD, CAD, and left renal artery stenosis, is admitted to the hospital for uncontrolled hypertension. He has not seen a doc since 2003, when he was previously admitted for uncontrolled hypertension and NSTEMI. At that time, he was diagnosed with left renal artery stenosis. Intervention was recommended, but he never followed up. He currently takes no home meds. The only reason he came to the ER today was because he tripped on a rug and hurt his ankle. In triage, his BP was 224/128, although he was asymptomatic. The ER give the patient lasix 60mg IV x 1, lisinopril 20mg, and clonidine 0.3mg x 1. His follow-up BP is 154/98. He is still asymptomatic. The ER then calls you as the IM resident on call for admission.

    Labs in triage:
    Na: 136
    K: 2.8
    Cl: 108
    Bicarb: 22
    BUN: 18
    Cr. 1.0
    Ca: 9.4
    LFT's WNL

    CBC:
    WNL

    UA: WNL

    So, the patient is admitted for treatment of uncontrolled HTN. The only medications given are supplemental KCl. Overnight, his BP remains with a systolic 130-140. Good urine output. However, the next morning when you are checking labs, you discover:

    Na: 139
    K: 5.4
    Cl: 106
    Bicarb: 24
    BUN: 22
    Cr: 1.9
    Ca: 8.9

    CBC still normal.

    What is the cause of this patient's renal failure?
    A. Lasix
    B. Lisinopril
    C. Hypertensive emergency
    D. Lab error
    E. Dehydration

    And why did he have such severe hypokalemia on admission?
    A. Secondary hyperaldosteronism
    B. Primary hyperaldosteronism
    C. Shy-Drager Syndrome
    D. Addison's Disease
    E. Cushing's Disease
    Last edited by Statia Graduate; 05-09-2009 at 12:39 PM.

  2. #2
    RussianJoo's Avatar
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    well this is actually pretty easy just cause i remember this from basic sciences but i totally forget the pathophysiology..
    1)B. Ace-Inhibitors cause renal failure and are contraindicated in renal artery stenosis. (but I forget why and how)
    2) since it's due to his kidney's it would A) secondary hyperaldosteronism.
    Hollywood Upstairs School of Medicology, Class of 2010
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  3. #3
    Statia Graduate is offline Junior Member 510 points
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    Quote Originally Posted by RussianJoo View Post
    well this is actually pretty easy just cause i remember this from basic sciences but i totally forget the pathophysiology..
    1)B. Ace-Inhibitors cause renal failure and are contraindicated in renal artery stenosis. (but I forget why and how)
    2) since it's due to his kidney's it would A) secondary hyperaldosteronism.
    Okay, then you are correct! This came from a case two weeks ago. Too bad you weren't working in the ER that night!

    He was diagnosed in 2003 with left renal artery stenosis. ACE-I usually cause RF in patients with bilateral renal artery stenosis. Basically, he had undiagnosed bilateral renal artery stenosis. The right renal artery must have stenosed at some point between 2003 and two weeks ago. The moral of the story is that never use ACE-I in a patient like him unless you know what you are dealing with. He had no follow-up since 2003, and with the diagnosis of left stenosis, he was at high risk for right stenosis. lisinopril is a crappy drug to give to a pt with such high BP anyway.

    When the ER called me, my response was, "I'm sorry you gave WHAT?"

    ACE-I cause renal failure in patients with renal artery stenosis by blocking the angiotension II-mediated efferent arteriolar vasoconstriction, and therefore decreasing GFR.

  4. #4
    Statia Graduate is offline Junior Member 510 points
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    And the case continues

    Once this patient's Cr stablizes, what antihypertensive medication should you use? and why?
    A. clonidine
    B. spironolactone
    C. amlodipine
    D. HCTZ
    E. metoprolol

    What is the difference between hypertensive emergency and hypertensive urgency?

    When a patient presents with hypertensive emergency, you should lower the MAP a maximum of what? and why?
    A. 25%
    B. 50%
    C. 10%
    D. 33%
    E. 5%
    Last edited by Statia Graduate; 05-09-2009 at 02:24 PM.

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    1) HCTZ is the first line and is especially effective in AA's. but this guy might need multi drug therapy.

    2) I forget. emergency should be treated asap, urgency can wait a little, lol?

    3) A or B. you don't want to lower it to much too fast cause he'll have hypoperfusion of his organs and especially his brain. assuming this was a chronic hypertension.
    Hollywood Upstairs School of Medicology, Class of 2010
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  6. #6
    Statia Graduate is offline Junior Member 510 points
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    You are right about HCTZ in African-Americans. But not in this guy. Think of the mechanism of his HTN. It is due to activation of the renin-angiotensin system by decreased renal perfusion from his renal artery stenosis. So, the answer is B. spironolactone (one his Cr returns to normal).

    The difference between hypertensive emergency and urgency:

    Both are defined bya SBP>180 or DBP>120. But, hypertensive emergency has evidence of end-organ damage. Examples: AKI, elevated troponins, headaches, hypertensive encephalopathy, cerebral hemorrhage, visual disturbances. Hypertensive urgency is just the elevated BP.

    The answer to the last question is 25%. You do assume a patient who arrives to the ER with a BP this high usually lives with an elevated BP. Otherwise, they would be dead (quite frankly). You do not want to lower the MAP more than 25% because (and hear is where you are correct!) decreased perfusion to vital organs. Specifically, the brain. A suddenly drop in BP will result in a sudden decrease in cerebral perfusion, and cause the patient to stoke out.

    Are you getting addicted to these yet???

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    RussianJoo's Avatar
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    they're good breaks between chapters. and i am learning.

    thank you for doing this.
    Hollywood Upstairs School of Medicology, Class of 2010
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  8. #8
    Statia Graduate is offline Junior Member 510 points
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    No problem, I like doing it. I'm not getting them out of a book, some are real cases, others I'm pulling out of thin air.

    I'm studying for my IM boards right now. Out of curiousity I popped in on this forum, and realized that I could contribute. If we could get other people to play along, could really be fun.

    Hopefully this will help you guys for the Steps, but also I hope to teaach you how to apply what you learn in certain situations.

    Let me know if you have any other questions....

  9. #9
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    ok thanks a lot. will do. good luck on your boards.
    Hollywood Upstairs School of Medicology, Class of 2010
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  10. #10
    iammagi36 is offline Newbie 510 points
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    Quote Originally Posted by Statia Graduate View Post
    Okay, then you are correct! This came from a case two weeks ago. Too bad you weren't working in the ER that night!

    He was diagnosed in 2003 with left renal artery stenosis. ACE-I usually cause RF in patients with bilateral renal artery stenosis. Basically, he had undiagnosed bilateral renal artery stenosis. The right renal artery must have stenosed at some point between 2003 and two weeks ago. The moral of the story is that never use ACE-I in a patient like him unless you know what you are dealing with. He had no follow-up since 2003, and with the diagnosis of left stenosis, he was at high risk for right stenosis. lisinopril is a crappy drug to give to a pt with such high BP anyway.

    When the ER called me, my response was, "I'm sorry you gave WHAT?"

    ACE-I cause renal failure in patients with renal artery stenosis by blocking the angiotension II-mediated efferent arteriolar vasoconstriction, and therefore decreasing GFR.
    The same thing happened to my mother. She also had anemia, dehydration, and a bleeding ulcer so her blood volume was down. They chose to stent her renal artery and as a result suffered a stroke which paralysed her left side. In reviewing her records it appears she didn't need the stent. She just needed to recover from the anemia, dehydration, drugs and ulcer. She went in the hospital for a dislocated hip and left permanantly paralysed.

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