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JCU MB4 Term 1 Week 7 (Hypertension and Cardiac Failure)

1

A 54-year-old male was found to have a blood pressure of 160/94 mmHg on several occasions. The most likely cause?


  Chronic renal failure

  Thyrotoxicosis

  Phaeochromocytoma

  Primary hyperaldosteronism

  Essential HTN


Primary/essential hypertension is the most common common cause of high blood pressure.

2

Mr X, a 61-year-old SCUBA trainer and a heavy smoker complained of occipital headache and blurring of vision. His BP was 200/110 mmHg. After emergency treatment, Mr X underwent a biopsy which appears below. What is the arrow pointing to?

Hyperplastic arteriolosclerosis


  Caseous necrosis

  Amyloidosis

  Fibrinoid necrosis

  Collagenisation

  Hyalinosis


The image shows hyperplastic arteriolosclerosis, a consequence of malignant hypertension. There is concentric laminated wall thickening, luminal narrowing due to SMC proliferation and fibrinoid necrosis of the walls: 'onion skin' appearance.

3

A middle-aged man died in a car crash. His personal belongings included an unused strip of Atenolol. Appearance of his kidney at autospy is shown. What is the most likely diagnosis?

Grain-leather kidney


  No significant pathology

  Chronic pyelonephritis

  Chronic glomerulonephritis

  "Flea-bitten kidney"

  Benign nephrosclerosis


Small, nodular exterior of kidney ("grain-leather" appearance) is a common appearance of benign nephrosclerosis associated with non-malignant hypertension.

4

A middle-aged man died in a car crash. His personal belongings included an unused strip of Atenolol. The image below shows the suspected cause of his car crash. What is the diagnosis?

Cerebral infarction


  Intracerebral haemorrhage

  Cerebral infarction

  Glial tumour

  Tuberculoma of brain

  Subarachnoid haemorrhage


Note wedge-shaped appearance, consistent with ischaemia following occlusion of a supplying artery (likely thromboembolic).

5

A 61-year-old retired school teacher had mild hypertension not responding to treatment. She also complained of muscle weakness. Her plasma renin level was low. What is the most likely diagnosis?


  Renal ischaemia

  Adrenal cortical tumour

  Cushing's syndrome

  Primary hyperaldosteronism

  Chronic renal failure


Idiopathic hyperplasia is the most common cause of hyperaldosteronism (more so than tumours). Tumours are also more likely to cause severe rather than mild hypertension. Primary hyperaldosteronism is the most common cause of secondary hypertension. The muscle weakness is most likely to hypokalaemia. The other clue in this question is the low renin level. Renin levels are typically high with vascular causes of hypertension.

6

32-year-old woman with long-standing dysponeoa and cough. Afebrile. Recently developed pedal oedema. Chest examination shows bilateral crepitations, mid-diastolic murmur. Gross specimen of lung is shown. What is the diagnosis?

Congested lung


  Bronchopneumonia

  Lobar pneumonia

  Chronic venous congestion

  Pneumoconiosis

  Adenocarcinoma


Brown induration (fibrosis and haemosiderin deposition) of lung is shown, a common feature of chronic passive pulmonary congestion.

7

75-year-old man, died of chronic cor pulmonale. Liver at autopsy is shown. What is the diagnosis?

Nutmeg liver


  Cirrhosis of liver

  Fatty liver

  Hepatoma

  Heptatis

  Nutmeg liver


Chronic IVC and hepatic vein congestion causes dilation of the hepatic venules and perisinusoidal necrosis, resulting in a 'nutmeg' appearance. Yellowish change is due to fatty change in hepatocytes suffering from mild ischaemia.

8

48-year-old chronic alcoholic with exertional dyspnoea, cough, fatigue. Examination shows afebrile, generalised oedema, bilateral crepitations. No evidence of iscahemia or valvular disease. Gross heart specimen is shown. What is the diagnosis?

Dilated cardiomyopathy


  Rheumatic carditis

  Dilated cardiomyopathy

  Chronic cor pulmonale

  Atrial septal defect

  Ventricular septal defect


All four chambers are enlarged, which is a characteristic of dilated cardiomypoathy. To diagnose dilated cardiomyopathy, all other organic causes must be excluded, with is consistent with the lack of history of ischaema/valvular disease.

9

In a patient who has sustained myocardial injury, which of the following is the earliest step in the development of heart failure?


  Loss of parasympathetic impulses

  Sympathetic overactivity

  Renal vasoconstriction

  Renin-angiotensin-Aldosterone mechanism

  Sodium retention


Although sympathetic overactivity is first observed, the loss of parasympathetic activity is likely what leads to this relative overactivity.