Case Presentation Intern Chief Complaint Hypertension noted for

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Case Presentation 指導老師:盧美君醫師 Intern:錢燁誠

Case Presentation 指導老師:盧美君醫師 Intern:錢燁誠

Chief Complaint �Hypertension noted for 6 months

Chief Complaint �Hypertension noted for 6 months

Present Illness � 43 -year-old male with hypertension had only taken Chinese medicine previously

Present Illness � 43 -year-old male with hypertension had only taken Chinese medicine previously for 1 month. � 2016/8/12 成人健檢 � 8/12 BP: 155/110 mm. Hg ; Pulse: 76 bpm ◦ Initial home BP: 140~160+/90~100 mm. Hg � 8/19 BP: 163/109 mm. Hg ; Pulse: 73 bpm ◦ 給藥 ◦ Home BP: 130~140+/80~90 mm. Hg � 9/09 BP: 136/101 mm. Hg ; Pulse: 74 bpm �Denied short of breath, chest pain, any discomfort currently.

Past History and Personal History �Suspect hypertension �No known food and drug allergy �Denied

Past History and Personal History �Suspect hypertension �No known food and drug allergy �Denied smoking , alcohol , betel nuts

Family History �Father: Diabetes mellitus and hypertension �Grandmother(Father’s): Diabetes mellitus �Mother: Hypertension

Family History �Father: Diabetes mellitus and hypertension �Grandmother(Father’s): Diabetes mellitus �Mother: Hypertension

Physical Examination �身高: 175 cm �體重: 102 Kg �BMI: 33 �腰圍: 102 cm

Physical Examination �身高: 175 cm �體重: 102 Kg �BMI: 33 �腰圍: 102 cm

Physical Examination �General appearance: easy-looking, in no distress �Conscious: clear and well-oriented, E 4

Physical Examination �General appearance: easy-looking, in no distress �Conscious: clear and well-oriented, E 4 V 5 M 6 �HEENT: Conjunctiva: not pale. Sclera : not icteric �Chest: Clear. Wheezes (-) , Crackles (-) �Heart: Regular heart beat without murmur �Abdomen: Soft and flat. Normoactive bowel sound. Tenderness (-). Muscle guarding ()Mcburney tender (-) �Extremities: Freely movable. No Pitting edema �Neurological exam: No focal weakness. MP

Lab data 2016/8/5 HDL 38 (mg/d. L) M: >40 ALT (U/L) <=36 62 LDL

Lab data 2016/8/5 HDL 38 (mg/d. L) M: >40 ALT (U/L) <=36 62 LDL 110 (mg/d. L) <100 AST (U/L) <=34 40 TC 176 (mg/d. L) <200 TG 140 (mg/d. L) <150

以病患為中心LEARN �Listen ◦ Let’s hear ◦ A+B+C+D=X �Explain �Acknowledge �Recommend �Negotiate

以病患為中心LEARN �Listen ◦ Let’s hear ◦ A+B+C+D=X �Explain �Acknowledge �Recommend �Negotiate

C: Resorce 病患資源 �Family tree DM HTN DM Patient HTN

C: Resorce 病患資源 �Family tree DM HTN DM Patient HTN

C: Resorce 病患資源 �Family circle 爸爸 病人 媽媽

C: Resorce 病患資源 �Family circle 爸爸 病人 媽媽

C: Resorce 病患資源 �Family cycle

C: Resorce 病患資源 �Family cycle

LEARN-Recommend �Elevated liver function ◦ Favor fatty liver related �Suggest weight reduction �Keep follow

LEARN-Recommend �Elevated liver function ◦ Favor fatty liver related �Suggest weight reduction �Keep follow up liver function �Check HBV/HCV ststus �Arrange echo follow up �Hypertension ◦ Add Exforge on 8/19 ◦ Change to Exforge HCT on 9/9

LEARN-Negotiate �Impression: ◦ Essential (Primary) hypertension �Exforge HCT(Amlodipine 5 mg +Valsartan 160 mg +

LEARN-Negotiate �Impression: ◦ Essential (Primary) hypertension �Exforge HCT(Amlodipine 5 mg +Valsartan 160 mg + HCTZ 12. 5 mg) 1# QD � Arrange abdominal echo, HBs. Ag, anti -HCV, AST, ALT �病人接受繼續服用藥物並於三週後追蹤 治療

Discussion-High blood pressure Adult with blood pressure measured Measuring blood pressure Hypertension in pregnency

Discussion-High blood pressure Adult with blood pressure measured Measuring blood pressure Hypertension in pregnency Chronic HTN Gestationa l HTN Preeclampsia HTN

Chronic HTN 1. 發現懷孕 2天內,停用 ACEI, ARB, chlorothiazide 2. 限鹽 1. 目標BP: <150/100 mm.

Chronic HTN 1. 發現懷孕 2天內,停用 ACEI, ARB, chlorothiazide 2. 限鹽 1. 目標BP: <150/100 mm. Hg 2. Target organ damage: <140/90 mm. Hg 3. DBP不得小於 80 mm. Hg Preeclampsia HTN Gestationa l HTN 1. Proteinuria and BP 2. Risk of preeclampsia Mild (140/90149/99 mm. Hg) 不用治療 Risk of pre-eclampsia: 1. first pregnancy 2. age 40 years or older 3. DM, kidney disease 4. BMI 35 kg/m 2 or more at first visit 5. family history of pre-eclampsia Moderate (150/100159/109 mm. Hg) Labetalol 目標BP: <150/80100 mm. Hg 量BP最少 每天 4 次 Severe (160/110 mm. Hg) Labetalol 目標BP: <150/80100 mm. Hg 1. 量BP最 少每天 4 次 2. 每天測

Diagnosis: 140/90 mm. Hg HTN not diagnosi s 1. HBPM:最少連續4天早晚各量 2次,坐著量血壓,每 次間隔 1分鐘前後測兩次 2.

Diagnosis: 140/90 mm. Hg HTN not diagnosi s 1. HBPM:最少連續4天早晚各量 2次,坐著量血壓,每 次間隔 1分鐘前後測兩次 2. ABPM:在醒著期間,至少每小時量兩次,至少達 14 次的平均�有超過 3. Severe HTN: SBP>=180 mm. Hg or DBP>=110 mm. Hg , 立即給藥 HTN diagnosis 是否藥物治療 最少 5年 追蹤 1次 生活習慣: 1. Regular exercise 2. Reduced alcohol consumption 3. Reduced excessive consumption of coffee and other caffeine-rich products. 4. Low sodium dietary 5. Stop smoking. 6. Group working

治療目標: 1. <80歲病人:BP< 140/90 mm. Hg 2. >80歲病人:BP<150/90 mm. Hg Drug for HTN <55

治療目標: 1. <80歲病人:BP< 140/90 mm. Hg 2. >80歲病人:BP<150/90 mm. Hg Drug for HTN <55 歲 >55歲or任何年紀的非洲黑 人 ACEI(or ARB) CCB ACEI(or ARB)+CCB+thiazide-like diuretic 1. 血中K<=4. 5 mmol/L : low-dose spironolactone (25 mg once daily) 2. 血中K>4. 5 mmol/L : higher-dose thiazide-like diuretic 每年追蹤

Thanks for your attention

Thanks for your attention