Diagnostic Tests for Portal hypertension
Portal hypertension Tests: Book Excerpts
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Portal hypertension Diagnosis: Book Excerpts
Diagnostic Tests for Portal hypertension: Online Medical Books
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HYPERTENSION:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
Routine diagnostic tests include a CBC, sedimentation rate, chemistry panel, total and high-density lipoprotein (HDL) cholesterol, a VDRL test, urinalysis including microscopic, a urine culture with colony count and sensitivity, and an EKG, chest x-ray, and flat plate of the abdomen for kidney size.
If these are normal, a nephrologist should be consulted before undertaking expensive diagnostic tests. It may be wise to observe the results of treatment before further testing also.
Additional tests that may be ordered are an intravenous pyelogram, a 24-hr urine catecholamine, a serum cortisol, a plasma renin level, a 24-hr urine aldosterone determination, a cystoscopy, and retrograde pyelography. A 24-hr free cortisol may be more useful in diagnosing Cushing's syndrome than serum free cortisone. Renal angiography used to be done more frequently, but should be considered in sudden onset of hypertension in the elderly and in hypertension that is resistant to treatment.
Twenty-four-hr blood pressure monitoring can be useful both in diagnosis and in evaluating the results of therapy. Magnetic resonance angiography is a good noninvasive alternative to renal angiography.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Blood pressure increase [Hypertension]:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If you detect sharply elevated blood pressure, quickly rule out possible life-threatening causes. (See Managing elevated blood pressure.)
After ruling out life-threatening causes, complete a more leisurely history and physical examination. Determine if the patient has a history of cardiovascular or cerebrovascular disease, diabetes, or renal disease. Ask about a family history of high blood pressure — a likely finding with essential hypertension, pheochromocytoma, or polycystic kidney disease. Then ask about its onset. Did high blood pressure appear abruptly? Ask the patient's age. The sudden onset of high blood pressure in middle-aged or elderly patients suggests renovascular stenosis. Although essential hypertension may begin in childhood, it typically isn't diagnosed until near age 35. Pheochromocytoma and primary aldosteronism usually occur between ages 40 and 60. If you suspect either, check for orthostatic hypotension. Take the patient's blood pressure with him lying down, sitting, and then standing. Normally, systolic pressure falls and diastolic pressure rises on standing. With orthostatic hypotension, both pressures fall.
Note headache, palpitations, blurred vision, and sweating. Ask about wine-colored urine and decreased urine output; these signs suggest glomerulonephritis, which can cause elevated blood pressure.
Obtain a drug history, including past and present prescriptions, herbal preparations, and over-the-counter drugs (especially decongestants). If the patient is already taking an antihypertensive, determine how well he complies with the regimen. Ask about his perception of elevated blood pressure. How serious does he believe it is? Does he expect drug therapy to help? Explore psychosocial or environmental factors that may impact blood pressure control.
Follow up the history with a thorough physical examination. Using a funduscope, check for intraocular hemorrhage, exudate, and papilledema, which characterize severe hypertension. Perform a thorough cardiovascular assessment. Check for carotid bruits and jugular vein distention. Assess skin color, temperature, and turgor. Palpate peripheral pulses. Auscultate for abnormal heart sounds (gallops, louder second sound, murmurs), rate (bradycardia, tachycardia), or rhythm. Then auscultate for abnormal breath sounds (crackles, wheezing), rate (bradypnea, tachypnea), or rhythm.
Palpate the abdomen for tenderness, masses, or liver enlargement. Auscultate for abdominal bruits. Renal artery stenosis produces bruits over the upper abdomen or in the costovertebral angles. Easily palpable, enlarged kidneys and a large, tender liver suggest polycystic kidney disease. Obtain a urine sample to check for microscopic hematuria.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Blood pressure increase [Hypertension]:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If you detect sharply elevated blood pressure, quickly rule out possible life-threatening causes. (See Managing elevated blood pressure.)
After ruling out life-threatening causes, complete a more leisurely history and physical examination. Determine if the patient has a history of cardiovascular or cerebrovascular disease, diabetes, or renal disease. Ask about a family history of high blood pressure—a likely finding in patients with essential hypertension, pheochromocytoma, or polycystic kidney disease. Then ask about its onset. Did high blood pressure appear abruptly? Ask the patient’s age. Sudden onset of high blood pressure in middle-aged or elderly patients suggests renovascular stenosis. Although essential hypertension may begin in childhood, it typically isn’t diagnosed until near age 35. Pheochromocytoma and primary aldosteronism usually occur between ages 40 and 60. If you suspect either, check for orthostatic hypotension. Take the patient’s blood pressure with him supine, sitting, and then standing. Normally, systolic pressure falls and diastolic pressure rises on standing; in orthostatic hypotension, both pressures fall.
Note headache, palpitations, blurred vision, and sweating. Ask about wine-colored urine and decreased urine output; these signs suggest glomerulonephritis, which can cause elevated blood pressure.
Obtain a drug history, including past and present prescription and over-the-counter drugs (especially decongestants) as well as herbal preparations. If the patient is already taking an antihypertensive, determine how well he complies with the regimen. Ask about his perception of elevated blood pressure. How serious does he believe it is? Does he expect drug therapy to help? Explore psychosocial or environmental factors that may impact blood pressure control.
Follow up the history with a thorough physical examination. Using a funduscope, check for intraocular hemorrhage, exudate, and papilledema, which characterize severe hypertension. Perform a thorough cardiovascular assessment. Check for carotid bruits and jugular vein distention. Assess skin color, temperature, and turgor. Palpate peripheral pulses. Auscultate for abnormal heart sounds (gallops, louder second sound, murmurs), rate (bradycardia, tachycardia), or rhythm. Then auscultate for abnormal breath sounds (crackles, wheezing), rate (bradypnea, tachypnea), or rhythm.
Palpate the abdomen for tenderness, masses, or liver enlargement. Auscultate for abdominal bruits. Renal artery stenosis produces bruits over the upper abdomen or in the costovertebral angles. Easily palpable, enlarged kidneys and a large, tender liver suggest polycystic kidney disease. Obtain a urine specimen to check for microscopic hematuria.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Hypertension:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Blood pressure measurement. Use a standardized technique (2,3) when measuring blood pressure to avoid spuriously high or low values. Patients should be seated in a chair, upright with back support, feet flat on the floor, arms bared, and supported at heart level. The patient should be resting at least 5 minutes before blood pressure measurements are taken. Stimulants such as nicotine and caffeine should be avoided at least 30 minutes prior to measurement. Appropriate cuff size is very important; the bladder within the cuff should circle at least 80% of the arm. Initial blood pressure measurements should include both arms; the arm with the higher reading should be used thereafter. It is recommended that two or more readings, separated by 2 minutes, be averaged. If the first two readings differ by more than 5 mm Hg, then additional readings should be obtained and averaged.
B. Additional physical examination. Height and weight should be measured. In a focused physical examination, pay particular attention to the fundi (for hemorrhages or vascular changes), the carotid arteries (for bruits), the heart (for murmurs), the abdomen (for bruits), and the extremities (for pulses, bruits, edema).
Testing
A. Routine clinical laboratory tests. These include a urinalysis, hemoglobin, serum electrolytes, blood urea nitrogen, creatinine, blood glucose, total cholesterol, and high density lipoprotein (HDL) cholesterol. Obtain a 12-lead electrocardiogram.
B. Optional laboratory tests and studies. Additional testing may be warranted given the findings on history, physical examination, or the initial laboratory screening. Specifically, for patients with diabetes, urine microalbumin and serum glycohemoglobin. For patients with an elevated screening cholesterol, low-density lipoprotein (LDL) cholesterol and triglycerides. For patients with proteinuria on initial screening, 24-hour urinary protein and creatinine clearance (Chapter 16.6).
C. Blood pressure measurement outside the office. Self-measurement and ambulatory blood pressure monitoring are generally unnecessary but may be useful in certain circumstances. Self-measurement can help identify patients with “white coat hypertension.” Potentially, it may help assess response to antihypertensive medications and improve patient compliance. Ambulatory blood pressure monitoring is significantly more expensive and should not be used routinely; however, it can also be useful in evaluating suspected “white coat hypertension.”
Diagnostic assessment
A. Table 7.6 provides a summary of the sixth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC-VI).
B. Important considerations in the assessment of high blood pressure:
1. The patient should not be acutely ill or already on antihypertensive agents.
2. Classification should be based on the average of two or more readings taken at each of two or more visits after an initial screening.
3. When the systolic and diastolic blood pressures fall into different classifications, the higher classification should be used.
4. For patients with renal insufficiency and greater than 1 g/d of proteinuria, a blood pressure of 125/75 is recommended.
5. For blood pressures greater than 160–170 over 105–110, the diagnosis of HTN is probable even without additional measurements.
6. Follow-up may need to be modified based on the patient’s cardiovascular risk factors, history of prior blood pressure measurements, or evidence of target organ disease.
C. Secondary HTN. Secondary causes of HTN should be considered in patients responding poorly to medications, (particularly those with previously well-controlled HTN); in patients with stage 3 HTN; and those with sudden onset HTN. Many potential causes are found for secondary HTN. Some of the relatively more common causes and possible findings found during screening include:
1. Aortic coarctation
a. Short, rough systolic murmur in the second left interspace (Chapter 7.7)
b. Bruits heard over the back
c. Marked decrease in femoral pulses or blood pressures in the legs
2. Cushing’s disease
a. Central obesity with wasted extremities
b. Atrophic skin with abdominal striae and poor wound healing
c. Hyperglycemia (Chapter 14.1)
3. Exogenous substances. History of prescription drug, illicit drug, or alcohol use.
4. Primary hyperaldosteronism
a. Muscle weakness and cramps
b. Serum potassium less than 3.5 mEq/L off diuretics or less than 3.0 mEq/L on diuretics
5. Renal disease
a. Proteinuria
b. Elevated creatinine
6. Renal vascular hypertension
a. New onset HTN over the age of 55 years (particularly with history of smoking) or HTN in a child aged less than 12 years
b. Sudden increase in previously well-controlled blood pressure
c. Failure of triple drug therapy
d. Periumbilical bruit with radiation to the flanks
7. Pheochromocytoma
a. Anxiety, headaches, palpitations tremor, and excessive sweating
b. Weight loss (Chapter 2.13)
c. Orthostatic hypotension
d. Rapid pulse (Chapter 7.12)
References
1. American Heart Association [Web Page]. http://www.amhrt.org
2. Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The sixth report of Joint National Committee on Prevention, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med 1997;157: 2413–2446.
3. Izzo JL, Black HR. Hypertension primer: the essentials of high blood pressure, 2nd ed. Chicago: American Heart Association, 1997.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Hypertension:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
The level of blood pressure associated with 50% increase in cardiovascular mortality: men younger than 45 years old, 130/90; men older than 45 years, 140/95; women, 160/95. An ankle-brachial systolic blood pressure ratio of less than 0.9 predicts a fourfold increase in cardiovascular mortality.
Clues to secondary hypertension include onset at a young age (,35), abrupt onset of hypertension, blood pressure difficult to control requiring high dosages of two or more drugs, and very high or labile blood pressure. Hypertension with relative tachycardia may be a clue to sympathetic effect or diastolic dysfunction. Headaches with severe hypertension are occipital and worse in the morning.
Hypertensive end organ damage must be searched for when the diastolic BP is greater than 130 mm Hg and the patient exhibits confusion, dyspnea, restlessness, or blurred vision. Perform fundoscopy looking for papilledema or retinal hemorrhages, and cardiopulmonary exam for third heart sound or bibasilar rales. Clues to hypertension-associated left ventricular hypertrophy include a fourth heart sound, an apical impulse greater than two intercostal spaces, a holosystolic sustained apical impulse diameter, and a hypertensive response to exercise ( .210 systolic). Cotton wool spots, which are caused by anoxic edema with axon degeneration, are seen in advanced hypertension (also in diabetes, dysproteinemia, and fat emboli).
Grading hypertensive retinopathy provides a marker of end-organ damage, which is tied to prognosis:
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Pulse pressure, widened:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
After you detect a widened pulse pressure, assess for signs and symptoms of heart failure, such as crackles, dyspnea, and jugular vein distention. Also check for changes in skin temperature and color, strength of peripheral pulses, and LOC. Auscultate the heart for murmurs. Check for peripheral edema.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Hypertension:
Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
BP can bemeasured at any age, but it should be measured in any child ≥3yrs of age each year. Any infant or child with unexplained heartmurmur, cardiomegaly, decreased femoral pulses, abdominal mass,seizures, any suspicion of cardiovascular or renal disease, or anyacute severe illness should have BP measured.Arm BP should be measured with childsitting or supine with the cubital fossa at heart level. Width ofbladder cuff should cover two-thirds of distance between shoulderand elbow. Phase 1 and 5 Korotkoff sounds should be recorded. Ithas now been determined that phase 5 Korotkoff sound (disappearanceof Korotkoff sound) is reliable measure of diastolic BP in childrenof all ages. In child suspected of having hypertension, BP shouldbe measured in both arms and in at least 1 leg initially.Complete history and physical examshould be performed in any child with hypertension. Extent of evaluationdepends on child's age, clinical presentation and findings,family history, level of BP, and whether increase in BP is transientor sustained. Age
At any age, stress in form of anxiety, pain,or trauma is common cause of transient hypertension.Common and uncommon causes of sustained hypertensionby age are listed previously.In pediatric population, renal parenchymaldisease and renal artery stenosis are most common causes of severehypertension.Generally, the younger the child and higherthe BP, the more likely it is that an identifiable cause will befound.
Clinical Presentation
Childrenwith mild increase in BP are usually asymptomatic.Infants <1 yr of age withsevere hypertension may have feeding problems, vomiting, irritability,failure to thrive, respiratory distress, cardiac failure, and seizures.Older children with severe hypertensionmay have severe headache, blurred vision, funduscopic changes, focalor generalized seizures, or cardiac failure. Family History
Many children and adolescents with primaryhypertension often have positive family history of hypertension.Polycystic kidney disease and glucocorticoid-remediable aldosteronismare genetic diseases associated with hypertension.
Level of Blood Pressure
When singleBP measurement indicative of increased BP has been recorded in asymptomaticchild, several BP measurements should be made subsequently to determinewhether hypertension truly exists.If BP is in ninety-fifth percentilefor age, gender, and height, and especially if family history ispositive for primary hypertension and child is overweight, diagnosisis most likely primary hypertension.Several tests should be performed initially:CBC, UA, blood urea nitrogen, serum electrolytes and creatinine,and renal U/S.If results of these tests are normal,recommendations for decreasing salt intake and weight, and increasingexercise, should be made.If BP becomes normal, no other investigationsare necessary, but the BP should be measured periodically. If primary hypertension seems unlikelybased on negative family history, lack of obesity, and young age,the same tests should be performed.Cortical imaging may be useful in child withhistory of significant vesicoureteral reflux to look for focal scarring.Urinary tract obstruction may needto be investigated by combination of studies, including voidingcystourethrography, intravenous urography, and diuretic renography.If diagnosis remains uncertain, plasmarenin activity (PRA) should be measured because low PRA is usefulscreening test for mineralocorticoid excess. Plasma aldosteronealso should be measured. Finally, renal angiography should be considered.Cardiac organ damage can be evaluatedby echocardiography. In all individuals with severe hypertension,investigations should search for underlying cause.Several testsshould be performed: CBC with differential and platelet counts,UA, urine culture, serum electrolytes and creatinine, blood ureanitrogen, abdominal U/S, chest radiography, and echocardiography.Other useful tests include plasma reninactivity, plasma aldosterone, morning and evening serum cortisol,urine timed collection for catecholamines, measurement of specificplasma steroids to diagnose 17-alpha-hydroxylase and 11-beta-hydroxylasedeficiencies, and captopril renography.Renal angiography also should be considered. Transient vs Sustained Hypertension
In somecases, whether hypertension is transient or sustained can only bedetermined with passage of time. If hypertension is severe, whetherit is transient or sustained, immediate therapy for BP control isnecessary to prevent severe complications (e.g., cerebral hemorrhageand infarction). Investigations to determine underlying cause canbe performed once BP is under control.With sustained hypertension, repeatBP measurements must be made to assess its severity. Presence ofcardiomegaly, facial nerve palsy, and funduscopic changes of arteriolarnarrowing and arteriovenous nicking indicate long-standing severehypertension. These children must be investigated to determine causeof hypertension. >
» READ BOOK EXCERPT ONLINE »
Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Blood pressure, increased [Hypertension]:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If you detect sharply elevated blood pressure, quickly rule out possible life-threatening causes. (See Managing elevated blood pressure, page 84.)
After ruling out life-threatening causes, complete a history and physical examination. Determine if the patient has a history of cardiovascular or cerebrovascular disease, diabetes, or renal disease. Ask about a family history of high blood pressure—a likely finding with essential hypertension, pheochromocytoma, or polycystic kidney disease. Then ask about its onset. Did high blood pressure appear abruptly? Ask the patient's age. The sudden onset of high blood pressure in middle-aged or elderly patients suggests renovascular stenosis. Although essential hypertension may begin in childhood, it typically isn't diagnosed until near age 35. Pheochromocytoma and primary aldosteronism usually occur between ages 40 and 60. If you suspect either, check for orthostatic hypotension. Take the patient's blood pressure with him lying down, sitting, and then standing. Normally, systolic pressure falls and diastolic pressure rises on standing. With orthostatic hypotension, both pressures fall.
Note headache, palpitations, blurred vision, and sweating. Ask about wine-colored urine and decreased urine output; these signs suggest glomerulonephritis, which can cause elevated blood pressure.
Obtain a drug history, including past and present prescriptions, herbal medicines, and over-the-counter drugs (especially decongestants). If the patient is already taking an antihypertensive, determine how well he complies with the regimen. Ask about his perception of elevated blood pressure. How serious does he believe it is? Does he expect drug therapy to help? Explore psychosocial or environmental factors that may impact blood pressure control.
Follow up the history with a thorough physical examination. Using a funduscope, check for intraocular hemorrhage, exudate, and papilledema, which characterize severe hypertension. Perform a thorough cardiovascular assessment. Check for carotid bruits and jugular vein distention. Assess skin color, temperature, and turgor. Palpate peripheral pulses. Auscultate for abnormal heart sounds (such as gallops, louder second sound, or murmurs), rate (for example, bradycardia or tachycardia), or rhythm. Then auscultate for abnormal breath sounds (such as crackles or wheezing), rate (for example, bradypnea or tachypnea), or rhythm.
Palpate the abdomen for tenderness, masses, or liver enlargement. Auscultate for abdominal bruits. Renal artery stenosis produces bruits over the upper abdomen or in the costovertebral angles. Easily palpable, enlarged kidneys and a large, tender liver suggest polycystic kidney disease. Obtain a urine sample to check for microscopic hematuria.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
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