Orthostatic hypotension

Disease class: Hypotension

Hypertension

Disease class: Vascular diseases

Types

• Essential hypertension
• hypertension, Malignant
• hypertension, Pregnancy-induced
• hypertension, Renal
• Hypertensive retinopathy
• Masked hypertension
• White coat hypertension

 

Also known as

• Hypertensive diseases
  
• HTN (often written in medical records)
• High blood pressure

 

In brief

• Hypertension is a risk factor for many diseases, such as heart failure and renal failure.
• Hypertension is a risk factor for many sudden onset events, such as stroke.
• Minimising hypertension in the population significantly reduces the number of these diseases.

What is "high"?

European Heart Journal:34;2159–2219

• A commonly cited "normal" or "healthy" blood pressure for the average adult is 120/80. This means that the blood pressure is 120 mmHg during systole and 80 mmHg during diastole. The mean arterial pressure would be around 93 mmHg.
• Blood pressure varies with age. Children tend to have a lower blood pressure and old adults tend to have a higher blood pressure. 
• Frequent exercisers tend to have lower blood pressure values.
• In an acute situation, it is important to consider what is normal for the patient. Even a blood pressure of 120/80 could be high for them.

Symptoms and signs

• Hypertension is usually asymptomatic and detected by routine blood pressure measurement.
• Symptoms are more common with hypertensive crises or complications of chronic hypertension.
• Headache
• Light-headedness
• Visual disturbances

Risk factor for:

• Stroke
• Ischaemic heart disease
• Peripheral vascular disease
• Heart failure
• Dementia

 

Complications

• Hypertensive retinopathy
• Hypertensive nephropathy
• Hypertensive encephalopathy

 

Acute severe hypertension (urgency/crisis/emergency)

• When hypertension is severe enough it is known as a hypertensive urgency.
• The combination of hypertensive urgency, and signs of acute organ damage is a medical emergency. This is known as a hypertensive crisis, hypertensive emergency or malignant hypertension. Within minutes of a hypertensive crisis there is a significant risk of complications such as stroke.
• Rapid reduction in blood pressure can precipitate complications such as strokes.

Aetiology and pathophysiology

• If successful treatment of another disease causes the hypertension to completely resolve, then it is called secondary hypertension. The hypertension is "secondary" to that disease.
• There are many causes of secondary hypertension, particularly kidney dysfunction and endocrine disorders.
• Most cases of hypertension are essential hypertension (also called primary hypertension). This means that the body has failed to regulate the blood pressure within healthy limits, usually as a result of ageing. These patients may have no other medical conditions. Even if these patients have another medical condition, and it is completely reversed by treatment, the hypertension will not resolve.

Management

• Detect and confirm hypertension.
• Establish whether hypertension is primary or secondary. If secondary, what is the cause?
• Aim to control blood pressure values, minimising time out of target range.

Reducing blood pressure values to a target level should be done over the course of days. Rapid drops in blood pressure can precipitate strokes. 

• Lifestyle changes. Dietary changes. Reduction of salt intake.
• Medical therapy
• Vasodilator therapy

Hypotension

Disease class: Vascular diseases

Types

• hypotension, Orthostatic
• Post-exercise hypotension
• Shy-Drager syndrome

Retinal degeneration

Disease class: Retinal diseases

Types

• Macular degeneration
• Retinal drusen
• Retinal dystrophies
• Retinoschisis

Cerebral infarction

Disease class: Brain infarction

Types

• dementia, Multi-infarct
• infarction, Anterior cerebral artery
• infarction, Middle cerebral artery
• infarction, Posterior cerebral artery

Brain stem infarctions

Disease class: Brain infarction

Subtypes

• Lateral medullary syndrome

Lacunar stroke

Disease class: Cerebral small vessel diseases
 Disease class: Stroke

Also known as

• Lacunar stroke 
• Lacunar infarct (LACI) 

This is a type of ischaemic stroke. It results from the occlusion of small penetrating arteries which provide blood to the brain's deep structures.

 

Etymology

C. Miller Fisher observed "lacunae" (empty spaces) in the deep brain structures after occlusion of 200–800 μm penetrating arteries and connected them with five classic syndromes.

 

Types

• Pure motor stroke / hemiparesis (occurs in 33–50%)
• Ataxic hemiparesis (second most frequent)
• Dysarthria / clumsy hand (sometimes considered a variant of ataxic hemiparesis)
• Pure sensory stroke
• Mixed sensorimotor stroke 
• Silent lacunar infarction. There are no symptoms despite a loss of brain tissue. This often considered to be a non-stroke syndrome because a diagnosis of stroke can be made clinically. However a diagnosis of silent lacunar infarction must be identified by radiological imaging or post-mortem examination.

 

Epidemiology

• It is estimated that lacunar infarcts account for 25% of all ischaemic strokes.
• There is an annual incidence of approximately 15 per 100,000 people. 
• They may be more frequent in men .
• They may be more frequent in people of African, Mexican, and Hong Kong Chinese descent.

Carotid stenosis

Disease class: Carotid artery diseases

Chondrocalcinosis

Disease class: Arthritis
Disease class: Crystal arthropathies

Vulvitis

Disease class: Vulvar diseases

This refers to inflammation of the vulvae (the external female genitalia). 

The vulva includes the mons pubis, labia majora, labia minora, clitoris, vestibular bulbs, vulval vestibule, urinary meatus, the vaginal opening, and Bartholin's and Skene's vestibular glands.

Vaginitis

Disease class: Vaginal diseases

This refers to inflammation of the vagina.

[Geriatrics] Introduction

Also known as 

• Medical gerontology

This field specialises in diseases of the elderly. There is significant overlap with the fields of neurology, stroke medicine and rehabilitation medicine.

 

Subspecialties

• Almost every specialty can subspecialise in Geriatric medicine.

 

Etymology

• Ancient Greek γέρων (geron) = old man
• Ancient Greek ιατρός (iatros) = healer

 

History taking

 

Common presentations

• Severe fall
• Frequent falls
• Confusion
• New-onset
• Prolonged
• Inability to cope (acopia) 
• Reduced appetite
• Mobility impairment

 

Common problems

• Sarcopoenia 
• Osteopoenia
• Anaemia
• Pain
• Constipation
• Diarrhoea
• Vomiting
• Haemorrhage
• Incontinence 
• Urinary retention
• Dehydration
• Malnutrition 
• Cognitive impairment
• Memory impairment
• Blindness
• Deafness 
• Multimorbidity
• Polypharmacy
• Bereavement
• Single organ failure
• Multiple organ dysfunction syndrome

 

Relevant diseases:

• Hypertension
• Hypertensive retinopathy
• Hypotension
• Orthostatic hypotension
• Dyslipidaemias
• Urinary tract infection (UTI)
• Pneumonia 
• Gastroenteritis
• Osteoarthritis 
• Osteoporosis
• Paget's disease of bone  
• Avascular necrosis (AVN) of the femoral head
• Dementia 
• Delirium
• Hypothyroidism
• Type 2 diabetes
• Cataracts   
• Cancer
• Cardiovascular disease
• Cerebrovascular accident (stroke)
• Myocardial infarction (heart attack)
• Mesenteric ischaemia
• Peripheral vascular disease
• Chronic kidney disease 
• Diverticulitis
• Hernia
• Hypothermia 
• Anaemia
• Macular degeneration
• Rhabdomyolysis 

Brain infarction

Disease class: Brain ischaemia 

 Disease class: Stroke

Types

• Brain stem infarctions
• Cerebral infarction

 

See also

• If an infarction occurs in the heart : Myocardial infarction

Femoral neck fractures

Disease class: Bone fractures

Disease class: Hip fractures

Management

• Replacement arthroplasty

Peripheral arterial disease

Disease class: Peripheral vascular diseases

This is the narrowing of the blood vessels in the peripheries, usually the legs.
This is usually mediated by the process of atherosclerosis. 
Blood flow is restricted, causing pain in the affected area.
The symptoms usually worsen gradually and irreversibly, over a long time period.

Risk factors

• Chronic tobacco smoke exposure 
• Hyperlipidaemia
• Diabetes mellitus
• Advanced age 

 

Symptoms

• Intermittent claudication
• Muscle weakness 
• Muscle wasting
• Numbness
• Hair loss in the affected site
• Erectile dysfunction
• Arterial ulceration

 

Complications

• Critical limb ischaemia
• Digital amputation
• Limb amputation

 

Management  

• Promote smoking cessation
• Statin therapy 

• Angioplasty
• Percutaneous transluminal angioplasty (PTA)
• Stenting
• Endarterectomy
• Atherectomy 
• Vascular bypass
• Femoral popliteral bypass surgery

Pinguecula

Disease class: Conjunctival diseases 

 

A pinguecula is a white or yellow bump on the sclera, usually found close to the edge of the cornea. It is a thickening of the conjunctiva. It is a common age-related condition.

Rickets

 Disease class: bone diseases, Metabolic
Disease class: Calcium metabolism disorders
Disease class: Vitamin D deficiency

Types

• Osteomalacia
• Chronic kidney disease-Mineral and Bone disorder
• rickets, Hypophosphataemic

 

Keratoconjunctivitis sicca

Disease class: Dry eye syndromes

Asthenopia

Disease class: Eye diseases

Also known as

Eyestrain

Xerophthalmia

Disease class: Dry eye syndromes