SITUATIONAL PROBLEM K003302

1. Primary hyperaldosteronism. Symptomatic arterial hypertension II degree. Chronic kidney disease C2.

2. The diagnosis of “primary hyperaldosteronism (PHA)” was established on the basis of the patient’s complaints of increased blood pressure, refractory to combination therapy with ACE inhibitors and calcium antagonists (history data), age and gender, a combination of arterial hypertension and myasthenic syndrome, polyuria, paresthesia and nocturnal convulsions. In addition, changes detected on the ECG and in laboratory tests in the form of hypernatremia, hypokalemia, as well as hypostenuria and alkaline urine confirm the preliminary diagnosis. The primary nature of the disease is established on the basis of the anamnesis – the absence of indications of conditions leading to secondary hyperaldosteronism (CHF, nephrotic syndrome, long-term use of diuretics, etc.), as well as a family history of cerebrovascular diseases at a young age. Establishing the degree of hypertension is based on the BP values measured at the time of admission.

The diagnosis of “chronic kidney disease (CKD) C2” was determined by the decrease in GFR to 88 ml/min.

3. The patient is recommended to determine the aldosterone-renin ratio (ARC) after the preliminary cancellation of Enalapril 2-3 weeks before the study. Imidazoline receptor agonists may be used to control blood pressure. The diagnosis will be confirmed by detecting low plasma renin activity (PRA) and increased secretion of aldosterone. If a high APC is detected, additional stress tests are carried out for the differential diagnosis of aldosteroma and hyperplasia of the adrenal cortex (test with a 4-hour walk, Furosemide, Captopril, Dexamethasone). Ultrasound of the kidneys, adrenal glands to visualize the formation in the projection of the adrenal glands, CT of the abdominal cavity and retroperitoneal space with

contrasting to clarify the localization and size of the formation or to identify hyperplasia of the adrenal cortex. Consultation with an ophthalmologist and ophthalmoscopy to assess the presence of hypertensive ophthalmopathy; ECHO-KG to assess the thickness of the walls of the myocardium, diastolic and systolic function, the state of the valvular apparatus.

4. Antagonists of mineralocorticoid receptors. The drugs of this group not only eliminate the effect of aldosterone at the renal and other potassium-secreting levels, but also inhibit the biosynthesis of aldosterone in the adrenal glands. Spironolactone at the lowest effective dose, starting at 25 mg per day, gradually increasing to 100 mg per day or more.

Alternative: Eplerenone, starting at 25 mg twice daily, is a selective mineralocorticoid receptor antagonist with no antiandrogenic and progestogenic properties, which reduces the incidence of side effects. With insufficient hypotensive effect, it is possible to add calcium antagonists. From the directions of non-drug therapy (influence on risk factors, the formation of healthy lifestyle skills): training in health school on hypertension, to talk about the importance of rational nutrition (first of all, include foods rich in potassium in the diet, reduce salt intake to 5 g / day, an increase in the consumption of plant foods, as well as a decrease in the consumption of animal fats.) and a gradual increase in physical activity (moderate aerobic exercise – walking, swimming, fitness for at least 30 minutes 5-7 days a week), self-control of blood pressure.

5. The patient is shown an initial examination and the beginning of drug therapy at the outpatient stage, together with a cardiologist and an endocrinologist. If it is impossible to conduct an examination on an outpatient basis (CT, stress tests) – the decision on hospitalization in the endocrinology department. If a formation in the projection of the adrenal glands (aldosteroma) is detected, an examination by a surgeon and hospitalization in the department of endocrine surgery for surgical treatment (one- or two-sided adrenalectomy followed by replacement therapy) is detected.

In the future, the patient is under the supervision of an endocrinologist and a cardiologist.

CASE STUDY 62 [K003303]

Instructions: READ THE SITUATION AND GIVE DETAILED ANSWERS TO THE QUESTIONS

Main part

A 42-year-old woman, a lawyer, came to the local doctor with complaints of attacks of a sudden increase in blood pressure to 200/110 mm Hg and above, accompanied by headache, dizziness, palpitations, anxiety, fear, trembling all over the body, sweating . The duration of such attacks ranged from several minutes to 1 hour.

From the anamnesis it is known that for the first time such attacks began to disturb a year ago. The development of these attacks was usually preceded by physical exertion or nervous strain. On the advice of a friend, she took losartan 50 mg per day, however, without a visible effect. Repeatedly in the last 2-3 months. caused BSMP about a hypertensive crisis. However, due to the fact that the attack passed independently before the arrival of the emergency hospital, she refused hospitalization. Over the past month, the above attacks have become more frequent up to 1 time per week, which was the reason to contact the local doctor. From the anamnesis of life: the mother has AH.

On examination: the condition is relatively satisfactory, height 167, weight 62 kg, BMI 22.23 kg/m2. The skin is pale, moist. In the lungs – vesicular breathing. BH – 17 per minute. Heart sounds are clear, rhythmic. Heart rate – 86 per minute. BP – 128/80 mm Hg. Art. Language

clean, wet. The abdomen is soft and painless. The liver and spleen are not enlarged. Tapping in the region of the kidneys is painless on both sides.

In the analyzes: KLA, OAM within the normal range; total cholesterol – 4.8 mmol / l, TG – 1.3 mmol / l, HDL-C – 1.2 mmol / l; LDL-C – 2.4 mmol / l, fasting serum glucose

– 6.4 mmol / l, creatinine – 64 μmol / l, GFR (according to the CKD-EPI formula) = 103 ml / min; ECG: sinus rhythm, 85 beats per minute, angle α – 30°, Sokolov-Lyon index 38 mm.

Questions:

1. Suggest the most likely diagnosis.

2. Justify your diagnosis.

3. Draw up and justify a plan for an additional examination of the patient.

4. What drug and non-drug therapy would you recommend to the patient? Justify your choice.

5. Draw up and justify the routing of this patient, including the determination of the necessary stage of medical care, the issues of examination of disability.

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