Hypertension

A 72-year-old man sought medical evaluationafter he awoke and was unableto open his right eyelid (A). He deniedpain, recent trauma, and diplopia. Thispatient’s history included well-controlledhypertension and hypercholesterolemia,for which he was taking atorvastatin.He did not have diabetes.

For 2 days, a 68-year-old woman had watery, yellowish diarrhea with mucus and left lower quadrant pain. Her medical history included hypertension, diabetes mellitus, and congestive heart failure (CHF); she had left the hospital 5 days earlier following treatment of an exacerbation of CHF with intravenous furosemide and sodium and fluid restriction. The patient was taking furosemide, lisinopril, and glipizide; she denied any recent antibiotic therapy.

A 64-year-old woman with a history of diabetes, hypertension, and lymphoma was admitted to the hospital with a dull headache, conjunctival congestion, and slight dyspnea. Her pulse rate was 96 beats per minute; blood pressure, 146/68 mm Hg; and respiration rate, 22 breaths per minute. She also had increased jugular venous distention; cardiovascular and chest examination findings were normal. Edema of both arms and dilated blood vessels on the anterior chest wall were noted.

A 63-year-old woman seeks evaluation of a persistent, rough, red area onthe dorsum of her left index finger. The lesion has been present for severalmonths. The patient’s manicurist is convinced it is a wart.

A 65-year-old woman with a long history of hypertension treated with metoprolol and felodipine complained of dizziness, headache, nausea, and vomiting of acute onset. Her blood pressure was 220/110 mm Hg. She was drowsy and unable to stand or walk.

Many of my older women patients think theyare at much higher risk for breast cancer thancoronary heart disease (CHD). How can we raise women'sawareness about their risks of CHD and therebyencourage them to take measures to prevent it?

Q:Should I avoid angiotensin-converting enzyme (ACE) inhibitors in mypatients with progressive renal insufficiency?

Q:Many of my patients appear to have white-coathypertension: their pressure is elevated whenmeasured in my office-but normal when measured athome. Am I ignoring significant hypertension if I do nottreat these patients? Or am I overtreating if I do treat?

A 37-year-old woman presents to the emergency departmentwith a diffuse, sharp, pounding headache,which started 2 hours earlier. She rates her discomfort as4 on a scale of 1 to 10. Neck muscle soreness is also present,but the pain does not radiate.

A 72-year-old woman presented for her annual physical examination. She had been treated for tuberculosis 20 years earlier. The patient did not smoke cigarettes; she denied fever, chills, and rigors.

An 83-year-old man witha history of hypertensionand coronary arterydisease presented with a4-day history of mentalstatus changes, slurred speech, anddifficulty ambulating. He reported alack of appetite and weakness of severaldays.

Levofloxacin, 500 mg/d, had been prescribed for a 74-year-old woman who had a urinary tract infection. The patient had type 2 diabetes and hypertension. She was allergic to sulfa drugs. Two hours after taking the first oral dose of the antibiotic, painful blisters developed on the lower lip and soft palate.

A 49-year-old woman was admitted tothe hospital with a high fever ofabrupt onset, rigor, headache, myalgias,and profound prostration. Hertemperature was 41ºC (105.8ºF);blood pressure, 60/40 mm Hg; respirationrate, 30 breaths per minute;and pulse rate, 130 beats per minute.

Although the cardiovascular death ratehas declined in the United States, thenumber of hospitalizations for cardiacdisease has not. The improvement incare has been offset by an increase inthe number of older Americans. By2050, more than 100 million Americanswill be 60 years of age or older,and about 30 million will be older than80 years.

A recently married 24-year-old black man was brought (reluctantly) by his wife for consultation regarding the perpetual "dirt" on his back.

A 54-year-old Asian woman complained of itching from a newly erupted rash.