MINISTRY OF HEALTH OF UKRAINE



MINISTRY OF HEALTH PROTECTION OF UKRAINE

Vynnitsa national medical university named after M.I.Pyrogov

| |«CONFIRM» |

| |on methodical meeting of endocrinology department |

| |A chief of endocrinology department, prof. Vlasenko M.V. |

| |_________________ |

| |“_31_”_august___ 2012 y |

METHODOLOGICAL RECOMMENDATIONS

for independent work of students

by preparation for practical classes

|Scientific discipline |Internal medicine |

|Мodule № 3 |Current practice of internal medicine |

|substantial module №4 |Keeping patients in the Endocrinology Clinic |

|Topic |Management the patient with syndrome of an arterial hypertensia |

|Course |6 |

|Faculty |Medical № 1 |

Vynnitsa – 2012

Subject: Keeping the patient with the syndrome of hypertension in Endocrinology practice.

Actuality. Hypertension continues to be one of the most pressing problems of medicine. In Ukraine 21% of the adult population suffers from this disease. High frequency of complications leads to a reduction in life expectancy and disability population growth. Therefore, early diagnosis and appropriate treatment before the complications remains a priority issue. Medico-social problems prove the significance of the adoption of the national program of prevention and treatment of arterial hypertension in Ukraine.

In practice doctors often have difficulty in carrying out differential diagnosis of hypertension of different etiologies. Because blood pressure is controlled and supported by a number of endocrine mechanisms, the role of hormones involved in its regulation, most clearly reflected in their excess or deficiency. The greatest symptom of hypertension is characteristic for adrenal pathology (kortykosteroma, phaeochromocytoma, aldosteronoma) and hypothalamic-pituitary area of the brain (pituitary Cushing, hypothalamic syndrome). According to epidemiological studies, hypertension caused by primary hiperaldosteronizmom be determined in 0,3-1,5% of cases, Cushing's syndrome, pituitary - 0,1-0,6%, phaeochromocytoma - 0,1-0,3%, thyroid diseases - 0,2-3,3%. Arterial hypertension caused by diabetic nephropathy, occurs in 20-40% of patients with diabetes, which in total amounts to 1,8-4,2%.

Goal training: to teach students modern tactics of patients with the syndrome of endocrine hypertension, in practice, applying modern algorithms of diagnosis, treatment and prevention of complications of endocrine arterial hypertension based on Supervision of patients in the hospital and clinics.

The student must know:

1. Definition of endocrine hypertension classification.

2. Etiology and pathogenesis of hypertension adrenal origin.

3. Clinic PHAEOCHROMOCYTOMA, Kona syndrome (primary hiperaldosteronizm), Cushing's syndrome pituitary.

4. Etiology, pathogenesis, clinical hypertension of hypothalamic-pituitary origin (pituitary Cushing's).

5. Etiology, pathogenesis, clinical hypertension parathyroid (hyperparathyroidism).

6. Etiology, pathogenesis, clinical hypertension thyroid (hyperthyroidism).

7. Etiology, pathogenesis, clinical hypertension in diabetes mellitus type 1 - as a result of diabetic nephropathy, type 2 - induced insulin resistance and diabetic nephropathy).

8. Tactics of management (examination, treatment) patients with arterial hypertension of endocrine origin.

The student should be able to:

1. Conduct survey and physical examination patients with hypertension.

2. Measure and assess the level of hypertension.

3. Perform a differential diagnosis of syndrome of hypertension in endocrine disorders.

4. Draw up a plan of survey patients with hypertension, justify application of the basic methods of analysis, to determine the indications for their conduct.

5. Be able to evaluate and functional tests ("small" deksametazonova "great" dexamethasone test, load test veroshpironom).

6. Based on data analysis of clinical, laboratory and instrumental tests to detect and substantiate the diagnosis to formulate the main disease syndrome which is arterial hypertension.

7. Assign the appropriate treatment of symptomatic hypertension.

8. Demonstrate knowledge of principles of moral and ethical medical expert.

Classes are held in the form of students' work within small teams at the bedside of a patient with diabetes. According to the thorough study of the "Internal Medicine" for higher medical institutions III-IV accreditation levels, the organization of the curriculum should ensure student participation in the conduct of 3 - 4 patients with the syndrome of hypertension. During the curation sick student enjoys Protocol and fills a patient.

Timing practice (5,5 hrs.):

1. Morning medical conference - 30 min.;

2. Supervision of patients in the department - 2hod.;

3. Clinical analysis of medical history (seminar) - 1,5 hour.;

4. Independent work (study of literature, articles from the past 2 years, design blog, solving problems with step 2) - 1.5 hours.

DIAGNOSIS ALGORITHM HIPERKORTYTSYZMU

(Disease and Cushing's syndrome Itsenko)

Diagnostic workup

Signs hiperkortytsyzmu:

• Resistant hypertension (diastolic) with resistance to antihypertensive drugs;

• Headaches, loss of vision;

• dysplastic obesity (abdomen as "apron", "misyatsepodibne" red face, limbs stonsheni, "climacteric" ear);

• marbling, stonshenist skin with pink and pustular rash array;

• dysmenorrhea, hirsutism, decreased potency;

• myocardial signs of circulatory failure;

• Osteoporosis (bone pain, pathological fractures).

Laboratory studies

1. Blood:

á erythrocytes

á Leucocytes

â Lymphocytes

â Eosinophils

á Blood Sugar

â Potassium

á Sodium

á Alkaline phosphatase

2. Urinalysis:

 Proteinuria, leukocyteuria, glucosuria

3. Determination 17OKS and 17 CC in daily urine: (Eskretsiya increased)

4.Hormonalni research

á Cortisol blood

ACTH: Normal or elevated in Cushing's disease, reduced the syndrome

Functional load samples:

 Deksametazonova small-sample (2mh/dobu x 2 days)

 - Deksametazonova large samples (8mh/dobu x 2 days)

Additional research methods

Radiography of the lumbar spine (L1-L4): (osteoporosis), adrenal ultrasound, CT, MRI of pituitary and adrenal

Treatment 1. Pathogenetic conservative:

- Radiotherapy

Blockers hypothalamic-pituitary-adrenal secretion (bromerhokryptyn, tsyprotheptadyn, Reserpine)

Blockers steroidogenesis cortex adrenal glands: Chloditane, mitotan

2.Symptomatychne treatment (correction of blood pressure):

-ACE inhibitors, Sartana

- Diuretics: thiazide, netiazydni, loops in combination with aldosterone antagonist (veroshpiron)

3.Hirurhichne treatment:

a) pituitary Cushing - transfenoyidalna adenomektomiya pituitary, with a large tumor or diffuse hyperplasia - transfenoyidalna total hipofizektomiya

b). Primary adrenal Cushing's syndrome:

- Adenoma and carcinoma (tumor removal)

-At hyperplasia - a bilateral adrenalectomy

- Ectopic ACTH - Cushing's syndrome dependent: eksterpatsiya tumor if you can find it

DIAGNOSIS ALGORITHM aldosteronoma

(Primary hiperaldosteronizm syndrome Kona)

Diagnostic workup

syndrome AH (AH): SC ↑,( headaches, loss of vision

neuromuscular syndrome:(

myasthenia gravis, paresthesia, paresis, muscle weakness, seizures

kaliypenichnoyi kidney( syndrome:

pronounced thirst, polyuria, nikturiya, the development of chronic pyelonephritis

Laboratory studies

1.Analiz urine: hipoizostenuriya, alkaline reaction,

polyuria

2. Biochemical analysis of blood:

hypokalemia 120 pg / ml

↓ renin

4. Functional load

samples

Load test veroshpironom (spironolactone) 100 mg 4 p per day for 3 days. Potassium level increases> 1 mmol / liter.

Additional research methods

ECG (bradycardia, arrhythmia, AV-conduction slowing, prolongation of Q-T, pathologic U, depression, ST, T wave inversion

Ultrasound adrenal (adenoma or adrenal hyperplasia)

CT, MRI of adrenal glands (adrenal adenoma)

Treatment 1. 1. Conservative treatment (carried out on condition of bilateral adrenal cortex hyperplasia, if surgery can be performed and, if retained after surgery hiperten - Zia):

2. - To reduce AT / v strumenno dybazol injected 8.12 ml of 1% solution of magnesium sulfayt - 10-20 ml 20% solution. To quickly reduce blood pressure injected klofelin - 1,0 ml 0,01%. In the absence of effect - apply pentamin 2-3 ml 5% solution.

3. - To compensate for the deficiency of potassium injected potassium chloride solution. In severe hypokalaemia must be entered to 10-14 grams of potassium chloride during the day.

4. Aldosterone blockers (veroshpiron, spironolactone) in doses of 200-400 mg / d with subsequent dose reduction to 50 mg / day

Calcium-antagonists (amlodipin, nifidipin), ACE inhibitors (captopril, enalapril, lisinopril) is added, if the above treatment within 2 weeks of no effect.

2. Operative treatment is provided diagnosed aldosteronoma (removal of diseased adrenal). Preoperative patient preparation necessarily includes the use of aldosterone antagonists (veroshpiron, spironolactone) in doses of 400-600 mg / day for 2-3 weeks

DIAGNOSIS ALGORITHM PHAEOCHROMOCYTOMA

Diagnostic workup

syndrome AH (AH)(

  (Paroxysmal (classical) form, stable from the crisis, crisis-free stable form):

- Paroxysm pronounced AH-200 300mm.rt.st. with simultaneous increase in systolic and diastolic AP (crisis occurs spontaneously, sometimes triggered by physical or emotional stress, hypothermia, abdominal palpation, lasts for several tens of minutes. The attack stopped suddenly, AT reduced to normal or below their numbers, is marked drowsiness, skin warming and porozhevinnya , polyuria;

- No effect of the therapy vehicles of conventional hypotensive. The effect of α-blockers.

cardiac syndrome during crisis(

Palpitation, pain in the area of the heart, shortness of breath, arrhythmias (tachycardia, extrasystoles, migration pacemaker).

intestinal syndrome during( crisis

Pain in the epigastrium, nausea, vomiting, slyunotecha which becomes dry mouth, diarrhea.

Neuro-vegetative syndrome in a( crisis

The feeling of fear, anxiety, internal tremors, chills, sweating uncontrolled, pale skin and chest, headache, polyuria.

Laboratory studies

1. A blood test during the crisis: leukocytosis, hyperglycemia.

2.Analiz urine

Paroxysmal form:

Urine for 3 hours after the crisis in the CMC (vanililmyhdalevu K th) and Ca (catecholamines)

Document form:

Daily urine on CMC and SC 2 times (3 days to determine canceled all drugs)

3.Funktsionalni loading

samples

Histamine test: enter 0,1 ml 0,1% solution of histamine - is positive with increasing BP to 30-40 mmHg 2-3 min.

Tserukalova test: bring in / to 2.0 ml in saline tserukalu - considered to be positive with increasing levels of systolic pressure greater than 40 mm hg, diastolic - by 40 mmHg

Thropaphen test, prazozynom: in / to the introduction of 10 mg thropaphen phaeochromocytoma lowers BP to 60-40 mm. hg

 Additional research methods

Ultrasound and CT of adrenal glands (adrenal adenoma (90%)

CT pozanadnyrnykovyh tumors (10%): sympathetic ganglia, retroperitoneal space, mediastinum, small pelvis, nerve plexus abdominal

Treatment

1. Conservative treatment:

Treatment in mizhkryzovomu period:

- blockers(- Selective blockers (fenoksybenzamin) - starting dose 10 mg / day, subsequently increased to 20-120 mg / d;

1 -(- Selective blockers blockers: prazozyn (4-20 mg / day), doxazosin (1-16mh/dobu)

- Alpha + beta - blocker: carvedilol (625-50 mg 2 g / day) labetolol (50-200 mg / day);

- To enhance the therapeutic effect of blockers prescribed ACE inhibitors (enalapril), calcium antagonists (amlodipin).

2.Operatyvne (adrenalectomy)

Preoperative patient preparation is required "necessarily prevent hypertensive crisis include:

  - blocker (redzhytyn,( fentolamin, kardura, dalfaz, prazozyn, doxazosin). When expressed tachycardia - blocker.(appoint

First Aid at feohromotsytomnomu crisis

I. Create a patient calm conditions of stay in hospital (exclude physical, emotional stress, hypothermia, overheating), raise the head end of bed for orthostatic pressure reduction.

II. To lower blood pressure (BP):

1. Alpha-blocker:

Fentolaminu hydrochloride 2-4 mg or 1-2 ml of 2 0 / 0 Mr. thropaphen momentarily at 20.0 isotonic Mr. sodium chloride. Then the drug is injected every 5 minutes to lower blood pressure, and at its lower and stabilize the injected V / m at the same dose every 2-4 hours with a gradual shift to acceptance of selective blockers in tablets alfa1-blockers: prazozin 20 mg / day, doxazosin 16 mg / day, kamiren 16 mg / day, kardura 16 mg / day, dalfaz 16 mg / day.

2. When expressed stable tachycardia (more than 120 beats per minute), arrhythmia bring into / in the beta-blocker: propranolol / v, 5.2 mg drip rate of 0.1 mg / min, esmolol / v drip 250-500 mg / kg / min., later 50-100 mg / kg for 4 minutes; visken in / in 5 ml (1 mg) in 20ml Mr. glucose jet;

Alpha-Beta-blockers labetolol injected bolus of 20 mg over 2 min. More input is repeated every 10 minutes to 20-80 mg to obtain the effect (total maximum dose - 300 mg). When you enter a drop of 200 mg lobetololu raised in 200 ml 5 0 / 0 Mr. glucose and injected at a speed of 1-2 ml / min.

III. In developing kollapsu (Adrenalinsekretuyucha phaeochromocytoma) / v drip injected norepinephrine (2-4 mg diluted in 1000 ml of 50 / 0 Mr. glucose)

IV. In the absence of therapeutic effect of alpha and beta - blockers at 3 hours shows emergency surgery - removal of adrenal adenoma or pozanadnyrnykovoyi chromaffin tumor

Independent work

1. The study of literature

2. Endocrinology. Edited. Sci. PM Bodnar. New book. - Vinnytsya. - 2010. - 464p.

3. Guidelines "Differential diagnosis and treatment of endocrine arterial hypertension. Ed. prof.Botsyurko VI, NV dots.Skrypnyk and others. - Ivano-Frankivsk. - 2005. - 43s.

4. Educational supplies departments.

5. Order MZ of Ukraine from 08.05.2009 № 574 "On approval of protocols of care in" Endocrinology ".

2. Preparation of abstract classes on the topic from the article:

6. Endocrinology. Ed. MD Tronko (Kyiv)

7. The problems of endocrine disorders. Ed. YI Karachentsev (Kharkiv)

8. International Journal of Endocrinology. Ed. VI Pankiv (Donetsk)

9. Problems of Endocrinology and Endocrine Surgery Ed. OS Larin (Kyiv)

10. Journals therapeutic profile.

3. Solution tests and situational problems Step 2.

4. Writing reports of clinical analysis of patients.

 

 

Protocol analysis of clinical patient

Name _____________________________________________ patient __________________________________________________________________________________________________________________

Profession _______________________________ Age ______________

Complaints patient ___________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Anambes morbid ___________________________________________

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Anamnes _____________________________________________ vitae ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Results of physical examination of the patient: _________________

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Previous diagnosis: _______________________________________

___________________________________________________________________________________________________________________________________________________________________________

Which diseases should conduct a differential diagnosis:

1. ______________________________________________________

2. ______________________________________________________

3. ______________________________________________________

4. ______________________________________________________

5. ______________________________________________________

Test Plan: _________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Results of laboratory and instrumental examinations:

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Justification of clinical diagnosis: _________________________

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Clinical diagnosis: ________________________________________

The main diseases: ___________________________________

___________________________________________________________________________________________________________________________________________________________________________

Complications: ____________________________________________

__________________________________________________________________________________________________________________

Diseases: ____________________________________

___________________________________________________________________________________________________________________________________________________________________________

 Prediction: ________________________________________________

__________________________________________________________________________________________________________________

Able to work: __________________________________________

___________________________________________________________________________________________________________________________________________________________________________

Treatment: _______________________________________________

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Drug therapy: __________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Control of blood pressure: ________________________________________

Marks on learning practical skills

Number p / p and manipulation skills Signature

student / manager

1. Practical skills

1.1. Be able to conduct interviews, physical examination of the patient of hypertension syndrome.

1.2. Be able to analyze laboratory testing

1.3. Be able to assign therapy patients with hypertension

2. State of emergency

2.1. Be able to assist in crisis feohromotsytomnomu

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Tests baseline knowledge

1. For the AH is not characteristic of phaeochromocytoma:

1. paroxysm pronounced AH to 200-300 mm Hg. c. .. with simultaneous increase in systolic and diastolic AP

2. Effective therapy of conventional vehicles of hypotensive

3. The effect of α-blockers.

4. Crisis ends by a large number of urine

5. Crises may be accompanied by neuro-vegetative syndrome

2. Hypertension develops in all diseases except:

1. Conn syndrome

2. PHAEOCHROMOCYTOMA

3. Cushing's syndrome of pituitary

4. adrenal insufficiency

5. pituitary Cushing's

3. A diagnosis can be made syndrome Kona:

1. test with veroshpironom

2. deksametazonovyy small test

3. deksametazonovyy big test

4. ACTH stimulation test

5. prednisolone suppression test

4. What is blood pressure the most typical of uncomplicated diffuse toxic goiter?

1. Increased systolic and diastolic blood pressure decreased

2. Increased systolic and diastolic blood pressure

3. High diastolic and normal systolic arterial pressure

4. Elevated diastolic and systolic arterial pressure decreased

5. Reduced systolic and diastolic blood pressure

      

5. Select class of drugs ("gold standard") to reduce hypertension in patients with diabetic nephropathy:

1. ACE inhibitors, angiotensin receptor antagonists

2. The selective agonist of imidazoline receptors

3. β-blocker

4. Calcium channel blockers

5. Tiazydovi diuretics

6. In 1946 women after subtotal resection of the thyroid gland AT rose to 145/100 mmHg. Art., paresthesia appeared in the area face, extremities, shortness of breath, pain behind the breastbone, calf muscle cramps. Which drugs should be patient?

1. Calcium Preparations

2. Neuroleptic tools

3. Sedative

4. Nitrates

5. Beta blockers

7. Drug therapy of hypertension in primary hiperaldosteronizmi is appointed:

1. Veroshpironu (spironolactone) 200-400 mg / d

2. Hydrochlorothiazide 100-200 mg / d

3. Indapamide 2,5-5 mg / d

4. Hlortalidonu 25-50 mg / d

5. Furosemide 100-200 mg / d

8. Select the class of the "first line" to reduce hypertension in patients with Grave's disease:

1. ACE inhibitors, angiotensin receptor antagonists

2. Beta blockers

3. Selective α-blocker

4. Centrally acting drugs

5. Vazodylyatatory

1. Increased SA in menopausal symptoms cardiomyopathy accompanied by all except:

1. Increased AT

2. Cardialgia

3. Palpitation

4. Orthostatic hypotension

5. ECG changes

2. By the therapist asked a man 45 years, with complaints of pain in the area of the heart, increase blood pressure 150 / 95 mm. Hg. Art., decreased vision, increased hands, feet. What disease should be excluded?

1. Pituitary Cushing's

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