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Old 09-24-2012
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Arrow Gyrus Daily Questions; Internal Medicine #28

A 46-year-old white female presents to your office with concerns about her diagnosis of hypertension 1 month previously. She asks you about her likelihood of developing complications of hypertension, including renal failure and stroke. She denies any past medical history other than hypertension and has no symptoms that suggest secondary causes. She currently is taking hydrochlorothiazide 25 mg/d. She smokes half a pack of cigarettes daily and drinks alcohol no more than once per week. Her family history is significant for hypertension in both parents. Her mother died of a cerebrovascular accident. Her father is alive but has coronary artery disease and is on hemodialysis. Her blood pressure is 138/90. Body mass index is 23. She has no retinal exudates or other signs of hypertensive retinopathy. Her point of maximal cardiac impulse is not displaced but is sustained. Her rate and rhythm are regular and without gallops. She has good peripheral pulses. An electrocardiogram reveals an axis of 30 degrees with borderline voltage criteria for left ventricular hypertrophy. Creatinine is 1.0 mg/dL. Which of the following items in her history and physical examination is a risk factor for a poor prognosis in a patient with hypertension?

A. Family history of renal failure and cerebrovascular disease
B. Persistent elevation in blood pressure after the initiation of therapy
C. Ongoing tobacco use
D. Ongoing use of alcohol
E. Presence of left ventricular hypertrophy on ECG
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Old 09-24-2012
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I think C, knowing she is hypertense and continue to smoke is stupid.
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Old 09-24-2012
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Answer C .

Her weight is in control, she does not drink much .But she is a smoker which is causing hypertension and secondarily left ventricular hypertrophy.
Smoking has nicotine which is a stimulant of cardiovascular system.
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Old 09-24-2012
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You are correct.

The answer is C.

Several factors have been shown to confer an increased risk of complications from hypertension. In the patient described here there is only one: ongoing tobacco use.

Epidemiologic factors that have poorer prognosis include African- American race, male sex, and onset of hypertension in youth. In addition, comorbid factors that independently increase the risk of atherosclerosis worsen the prognosis in patients with hypertension. These factors include hypercholesterolemia, obesity, diabetes mellitus, and tobacco use.

Physical and laboratory examination showing evidence of end organ damage also may portend a poorer prognosis. This includes evidence of retinal damage or hypertensive heart disease with cardiac enlargement or congestive heart failure.

Furthermore, electrocardiographic evidence of ischemia or left ventricular strain but not left ventricular hypertrophy alone may predict worse outcomes. A family history of hypertensive complications does not worsen the prognosis if diastolic blood pressure is maintained at less than 110 mmHg.
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