Upload
abner-marsh
View
218
Download
0
Tags:
Embed Size (px)
Citation preview
History
Present Illness
• He had episodes of headache of few times per month for 1 year. The characteristic was a throbbing frontal headache aggravated from exercise and relieved by resting or analgesic drug such as paracetamol.
• 2 days prior to admission, his headache became progressively severe.
History (2)
Present illness• No nausea, vomiting, dyspnea, and orthopnea
• Vision was normal.
• No fever, cough, or sore throat recently
• Normal urination, no dysuria, hematuria, or oliguria
• No edema, rash, oral ulcer, anemia, abnormal bleeding, or arthralgia
• No history of previous hypertension or urinary tract infection.
History (3)
• No family history of hypertension or renal disease
• Development was normal.
• Complete vaccination as scheduled
• No history of any drug allergy
• No ingestion of any medications
Physical Examination
Vital signs: T 37.5 o C, P 76 /min, no delayed pulse and equal all extremities, RR 24 / min, Blood pressure
Right arm: 170/120 mmHg
Left arm: 165/110 mmHg
Right leg: 170/105 mmHg
Left leg: 170/110 mmHg
BW 23 kg (P10-25) Ht 126.5 cm (P 50)
BMI 14.37 kg/m2
Physical Examination (2)
General appearance: alert and cooperative, not pale, no jaundice, no dyspnea, no orthopnea, no puffy eyelids, no edema, and no cyanosis
Skin: no rash, no petechiae , no ecchymoses, no alopecia, no café au lait spots
HEENT: normal
Physical examination (3)
CVS: PMI at left 5th intercostals space, lateral to midclavicular line, no heaving or thrill, normal first and second heart sound, no murmur
RS: normal
Abdomen: soft, not tender, no palpable mass, liver and spleen not palpable, normal bowel sound , no abdominal bruit
Nervous system : Normal
No superficial lymphadenopathy
Problem list
1. Chronic headache for 1 yr with severe progressive headache for 2 days
2. Severe hypertension
3. Cardiomegaly
What is hypertension?
• Hypertension=average SBP and/or DBP ≥ 95th percentile for gender, age, and height on ≥ 3 separate occasions
• Prehypertension : BP 90th -95th or BP ≥ 120/80• Normotension : SBP and DBP ≤ 90th by age,
gender, and height or BP ≤ 120/80• Hypertension stage I : SBP and/or DBP 95th -99th
• Hypertension stage II : SBP and/or DBP ≥ 99th
Clinical manifestations of hypertension
• Most of the patients do not have symptom related to hypertension at the presentation.
• Chronic headache (10 %)
• Hypertensive encephalopathy (6.8%)
• Epistaxis (1.4%)
• Visual disturbance (1.4 %)
[ The Study of persistent hypertension in Thai children etiologies and outcome in J med association Thai 2006 ]
Hypertensive Emergency
• No specific level of BP
• Defined as a blood pressure high enough to cause acute injury to target organs
• Children are more prone to hypertensive encephalopathy than adults
Complication of hypertensive emergency
• The most common complications are
- Hypertensive encephalopathy
- Cerebral infarction and hemorrhage
- Facial palsy
- Visual symptoms
- Cardiac failure
- Renal failure
The Causes of Secondary Hypertension in Children and Adolescents
Cause Acute hypertension Chronic hypertension Etiology
Renal Acute glomerulonephritis Congenital defects Tumors of the kidney
Acute renal failure Chronic pyelonephritis Hypoplastic kidney
Hemolytic-uremic syndrome
Hydronephrosis Collagen vascular disease
Endocrine - Pheochromocytoma Primary aldosteronism
Hyperthyroidism Neuroblastoma
Vascular Renovascular trauma Coarctation of the aorta Renal arteriovenous fistula
Renal artery stenosis Neurofibromatosis
Takayasu arteritis Tuberous sclerosis
Neurogenic Increased intracranial pressure
Dysautonomia -
Guillain-Barré syndrome
Metabolic Hypercalcemia - -
Hypernatremia
Drugs Cocaine Nonsteroidal Anabolic steroids
Phencyclidine anti-inflammatory drugs Corticosteroids
Amphetamines Oral contraceptives Alcohol
Miscellaneous BurnsLeg traction
Heavy metal poisons -
Adapted from Daniels SR, Loggie JM: Essential hypertension. Adolesc Med State Art Rev 2:555, 1991.
The Causes of Secondary Hypertension in Children and Adolescents (2)
Cause Acute hypertension Chronic hypertension Etiology
Metabolic Hypercalcemia - -
Hypernatremia
Drugs Cocaine Nonsteroidal Anabolic steroids
Phencyclidine anti-inflammatory drugs Corticosteroids
Amphetamines Oral contraceptives Alcohol
Others BurnsLeg traction
Heavy metal poisons -
Adapted from Daniels SR, Loggie JM: Essential hypertension. Adolesc Med State Art Rev 2:555, 1991.
Etiology of Secondary Hypertension in Pediatrics
• 78% renal parenchymal
• 12% renovascular
• 2% coarctation of the aorta
• 0.5% pheochromocytoma
• 7.5% others
Ronald Portman,MD professor and director,division of pediatric nephrology and hypertension, University of Texus Houston, 2003
Cause of the persistent hypertension according to age group in Thailand
Age Cause No. of patient(%) 6-12 yr lupus nephritis 36.1
chronic renal failure 22.2 idiopathic nephrotic syndrome 5.6 IgA nephropathy 2.8 renovascular disase 13.9 drug induced 11.1 coarctation of aorta 2.8 Essential hypertension 2.8 unknown 2.8
[ The Study of persistent hypertension in Thai children etiologies and outcome in J med association Thai 2006 ]
The Causes of Secondary Hypertension as Suggested by History
History Suggests
Known urinary tract infection; recurrent abdominal or flank pain with frequency, urgency, dysuria; secondary enuresis
Renal disease
Joint pains, rash, fever, edema Renal disease, vasculitis
Complicated neonatal course, umbilical artery catheter Renal artery stenosis
Renal trauma Renal artery stenosis
Drug use (e.g., sympathomimetics, anabolic steroids, oral contraceptives, illicit drugs)
Drug-induced hypertension
Aberrant course or timing of secondary sexual characteristics; virilization
Adrenal disorder
Muscle cramping, constipation, weakness Hyperaldosteronism (primary or secondary)
Excessive sweating, episodes of pallor and flushing Pheochromocytoma
Adapted from Hiner LB, Falkner B: Renovascular hypertension in children. Pediatr Clin North Am 40:128-129, 1993.
The Causes of Secondary Hypertension as Suggested by Physical Examination
Adapted from Hiner LB, Falkner B: Renovascular hypertension in children. Pediatr Clin North Am 40:128-129, 1993.
Physical finding Possible secondary cause
Blood pressure
>140/100 at any age Multiple secondary causes
Leg < arm blood pressure Coarctation of the aorta
Poor growth Chronic renal disease
Short stature, features of Turner syndrome Coarctation of the aorta
Multiple café-au-lait spots or neurofibromas Renal artery stenosis, pheochromocytoma
Decreased or delayed pulse in leg Coarctation of the aorta
Vascular bruits
Over large vessels Arteritis
Over upper abdomen, flank Renal artery stenosis
Flank or upper quadrant mass Renal malformation, renal or adrenal tumor
Excessive virilization or secondary sex characteristics inappropriate for age
Adrenal disorder
Extremities
Edema Renal disease
Excessive sweating Pheochromocytoma
Adapted from Hiner LB, Falkner B: Renovascular hypertension in children. Pediatr Clin North Am 40:128-129, 1993.
Investigation
The first line
• Urinalysis• Urine culture• BUN , creatinine• 24 hr. urine for
vanillymandelic acid • Renal ultrasound
including Doppler study of renal ateries
• Complete blood count• Electrolyte• Calcium, Phosphate• Chest x- ray • EKG • Retinal examination
Investigation
The second line
• urine catecholamine
• plasma renin and aldosterone
• CT angiography
• ESR and ANA
Investigation
• CBC : Hb 12.1 g/dl Hct 35.3 % WBC 3890 cell/mm3 ( N 46%, L 39%, Mo 9%) Plt 187,000 cell/mm3
• UA : pH 6, Sp.gr. 1.015, protein 2+ ,ketone negative WBC 0-1 cell/HP , RBC 0-1 cell/HP, no dysmorphic RBC, no cast
• Urine protein/creatine : 0.8
• 24 hr. urine protein : 9 mg/kg/day
Investigation
• Blood chemistry : BUN 13.0 mg/dl, Cr 0.7 mg/dl, Na 137 mmol/L, K 3.1 mmol/L, Cl 102 mmol/L, HCO3 22 mmol/L
• Lipid profile : Chol 203 mg/dl, TG 68 mg/dl, HDL 66 mg/dl, LDL 123.4 mg/dl
• EKG : LVH by voltage criteria
• Fundoscopic examination : atherosclerosis grade II BE
Investigation
• Echocardiogram :
no coarctation of aorta, no irregularity or aneurysmal dilatation of abdominal aorta.
concentric LVH without LVOT obstruction.
good LV systolic function.
no structural heart disease.
Investigation
• Throat swab culture : normal flora
• Anti-streptolysin O : 576 IU/ml
• AntiDNAse B : 79.1 U/ml
• C3 : 105 mg/dl
• U/S : Bilateral hydronephrosis and hydroureter UVJ, possibly related with stricture at UVJ from megaureter or stenosis related with ectopic ureter.
• Tc-99m MAG3 : hydronephrosis and hydroureter both kidneys with no evidence of obstruction. Mild impair function of left kidney.
Renal parenchymal disease
• Acute glomerulonephritis• Lupus nephritis• Acute or chronic renal
failure• Nephrotic syndrome• IgA nephropathy• Henoch-Schonlein
nephritis
• Coarse renal scarring (reflux nephropathy, obstructive uropathy, neuropathic bladder)
• Polycystic kidney disease • Hemolytic uraemic
syndrome.
VESICOURETERAL REFLUX
• The retrograde passage of urine from the bladder into the upper urinary tract
• Incidence : 1 % of children• 2 categories : primary and secondary• Screening with a radionuclide cystogram of all
sibling < 3 year and any sibling with a UTI is appropriate.
older sibling may undergo renal U/S and if an abnormality is found, VCUG is recommended
The length of the submucosal
segment of the distal ureter is an important factor in
determining the effectiveness of the
ureteral valvular mechanism in
preventing VUR.
Clinical manifestation
• Prenatal presentation :
hydronephrosis via U/S (80% are male)
• Postnatal presentation : UTI
• In other children, VCUG is performed during evaluation for pathology of urinary tract
Treatment• Goal of treatment are to prevent
complication
• Surgery for severe VUR
• ATB prophylaxis for mild to moderate VUR
Nonpharmacologic treatment
• dietary salt restriction
• mineral supplementation
• weight control
• regular exercise
• life style modification
Indications for Antihypertensive drugs
• Symptomatic hypertension
• Secondary hypertension
• Hypertensive target-organ damage
• Persistent hypertension despite nonpharmacologic measure
• DM?
Antihypertensive drugs
• ACEI and Ca channel blocker are commonly prescribed in children
• Diuretics are usually adjunct therapy.
• Need regular long term follow up with special attention to target organ injury and underlying disease
Antihypertensive drugs for hypertensive emergency
Most useful
• Esmolol : IV 100-150 ug/kg/min
• Hydralazine : IV or IM 0.2-0.6 mg/kg/dose
• Labetalol : IV 0.2-1.0 mg/kg/dose
• Nicardipine : IV 1-3 mg/kg/min
• Sodium nitroprusside : IV 0.53-10 ug/kg/min
Management• Antihypertensive drug :
5Enalapril ( mg) ½ tab oral bid ttt tttt tt(30 ) 1
50Atenolol ( mg) ½ tab oral bid pc
• ATB prophylaxis : tttt t ttt tttt tt(80 )1
• At ward , BP 100-130 / 80-90 mmHg ,UA : protein 2+ , wc 0-1/HP
Home medications:
• 80 1Bactrim ( mg of TMP) tab oral hs
• t ttt tttt ttt (5 )• ttt tttt tt(30 ) 1• 50Atenolol ( mg) ½ tab oral bid pc
Progress Note
Surgery: bilateral re-implantation
(Cohen Cross trigone)
After surgery : no anti-hypertensive medications
(BP 117/80 mmHg)
Medications:– Bactrim (80 mg of TMP) ½ tab oral bid – Paracetamol (500) ½ tab oral prn for pain
q 4-6 hrs