CASE 1

Patient
60-year-old woman, moderately overweight (BMI=26). Treated for hypertension for 15
years.
(BMI=Body Mass Index; kg/m2)
Current complaints
Currently she has had several blood pressure elevations despite adhering to prescribed
antihypertensive treatment. During these hypertensive urgency situations she has had
moderate, dull headache and felt tension. Due to family problems her life was stressful in
the previous months.
She claims her regular antihypertensive medications (see below). She mentions that she has
been prescribed a new medicine that should be taken only in case of blood pressure
elevations above 170 mmHg.
Other diseases
Vertigo
Medications, natural products, dietary/herbal supplements taken
Regularly:
Meramyl HCT 5/25 tablet (ramipril and hydrochlorothiazide; for one year); one tablet/day
(morning)
Cardilopin 5 mg tablet (amlodipin; for one year); one tablet/day (evening)
Tensiomin 12.5 mg tablet (captopril, newly prescribed medicine) half a tablet when
neccessary.
Frontin 0.25 mg tablet (alprazolam, newly prescribed medicine); one tablet in the evening.
Lifestyle, profession
Non-smoker patient, works in an office. She drinks some alcohol occasionally. She does
physical activity regularly, (walking or cycling for one hour, 3 or 4 times a week). She prefers
low-fat foods and often eats fish (at least once a week). She pays special attention to follow
a variable diet rich in vegetables using a cookbook she received last year, designed specially
for cardiovascular patients. Thanks to her diet and the regular physical activity she gradually
lost 5 kgs during the past year.

Allergies
No known allergies
Other relevant information
The patient has an automatic upper arm electronic/digital sphygmomanometer which she
uses regularly. She records readings in a diary. She used to smoke (4-5 cigarettes daily),
but quitted smoking a year ago. She regularly drinks a light milkcoffee in the morning.
Case 2

MEDICAL HISTORY
Patient
40-year-old male patient, overweight (BMI=29).
Current complaints
The patient has no complaints. The occupational physician measured elevated blood
pressure (167/113 mmHg). Measurement has been repeated on three different occasions,
and hypertension was diagnosed. He claims his first antihypertensive medication.

Other diseases
No other known diseases.

Medications, natural products, dietary/herbal supplements taken

Regularly:
o proponolol 5 mg tablet :one tablet in the morning
Occasionally:
o Hova tablet (5.5 mg dried humulus extraction, 200.2 mg dried valeriana extraction, for
one year) for sleeping problems, approx. 1-2 times weekly
o Rennie chewable tablet (680 mg Calcium-carbonate, 80 mg basic magnesium carbonate,
for half a year), approx. 1-2 times weekly.

Lifestyle, profession
Works at an international firm in a leading position and he is often stressed. He smokes (10-
15 cigarettes/day). He does not follow a special diet. He likes spicy foods. He regularly drinks
beer while watching TV (1-2 liters daily).

Allergies
No known allergies

Other relevant information

He lives on his own. He used to do sport (e.g. running), now he has been is too busy for it
lately. His father died in at the age of 55 due to acute myocardial infarction.
Case 3
DW, a 78-year-old Caucasian man, presents to the emergency room with complaints
of a headache persisting over the last 3 days. Repeated blood pressure
measurements average 200/110 mm Hg. He reports no other symptoms and
physical examination and laboratory tests are unremarkable as is his past medical
history with the exception of hypertension diagnosed in his early 60s. DW reports
that he is struggling on a fixed retirement income with no prescription coverage and
takes “what I can afford.”

Other diseases
No other known diseases.

Medications, natural products, dietary/herbal supplements taken

- carvedilol 25 mg twice daily,
- amlodipine 10 mg once daily,
- torsemide (Demadex®) 10 mg once daily, and
- valsartan 320 mg once daily.

Lifestyle, profession
He smokes (10-15 cigarettes/day for 15 years). He likes spicy foods. He regularly drinks
alcohol (10-15 glass daily).
CASE 4
Patient History
Type 2 diabetes mellitus × 15 years
Coronary artery disease × 10 years (MIs in 2005 and 2010)
Tobacco use
History of back surgery in 2001
Allergies
No known drug allergies
Meds
- Diltiazem CD 240 mg once daily
- Nitroglycerin 0.4 mg sublingual (SL) as needed (last use yesterday after showering)
- Ibuprofen 600 mg twice daily for arthritis pain
- Vitamin B12 once daily
- Multivitamin daily
- Aspirin 325 mg once daily
Family History
Significant for early heart disease in father (MI at age 53)
Social History
She is disabled from a previous accident; she is married, has 6 children, and runs her own
business; she does not drink alcohol and smokes one to two packs of cigarettes per day.
P Examination
- Blood pressure 126/70 mm Hg,
- pulse 60 bpm and regular,
- respiratory rate 16/minute,
- Ht 5’8’’ (173 cm), Wt 251 lb (114 kg), body mass index (BMI): 38.2 kg/m2

Chest x-ray
Bilateral pleural effusions and cardiomegaly
Echocardiogram
Ejectin Fraction = 35%
Laboratory Values
Case 5
SD is a 55-year-old, 85 kg (187 lb) male who developed chest tightness while in a
store in Sun Valley, Idaho, after 4 hours of skiing. SD developed substernal chest
tightness at 2030 hours that radiated into his left arm following an altercation with
another patron in the men’s room. He became short of breath and diaphoretic. Local
paramedics were summoned and he was given three 0.4 mg sublingual nitroglycerin
tablets by mouth, 325 mg aspirin by mouth, and 5 mg metoprolol IV push without
relief of chest discomfort. SD presented to St. Matthew’s Hospital in Sun Valley at
21.15 hours. St. Matthew’s does not have a cardiac catheterization laboratory and
transport time to St. Matthew’s in Boise is 1.5 hours door to door via air transport.

Patient History
- Hypertension (HTN) 10 years
- Dyslipidemia 6 months
- Two-vessel coronary artery disease (60% right coronary artery [RCA] and
80% left anterior descending artery [LAD] occlusion) after intracoronary
CYPHERTM stent placement to the mid-LAD artery lesion 10 months ago.

Family History
Father with myocardial infarction at age 65; mother alive and well; one sibling with
hypertension

Social History
Smoked 1 pack per day 30 years, quit 10 weeks ago

Allergies
No known drug allergies

Meds
- Metoprolol 25 mg by mouth twice daily
- ASA 325 mg by mouth once daily
- Lovastatin 20 mg by mouth once daily at bedtime
- Enalapril 5 mg by mouth once daily

Labs
- Sodium 138 mEq/L (138 mmol/L),
- potassium 4.2 mEq/L (4.2 mmol/L),
- chloride 105 mEq/L (105 mmol/L),
- bicarbonate 24 mEq/L (24 mmol/L),
- serum creatinine 1.0 mg/dL (88.4 μmol/L),
- glucose 95 mg/dL (5.27 mmol/L),
- white blood cell count 9.9 × 103/mm3 (9.9 × 109/L),
- hemoglobin 15.7 g/dL (157 g/L or 9.7 mmol/L),
- hematocrit 47%,
- platelets 220 × 103/mm3 (220 × 109/L),
- brain natriuretic peptide 3238 pg/mL (3238 ng/L),
- troponin I 16 ng/mL (16 mcg/L),
- oxygen saturation 99% on room air
 - ECG: normal sinus rhythm, PR 0.16 s, QRS 0.08 s, QTc 0.38 s, occasional polymorphic
premature ventricular contractions, 3 mm
- ST-segment elevation anterior leads
CXR
congestive heart failure, borderline upper normal heart size
Echocardiogram
hypocontractile left ventricle, akinesis of anterior apical wall, ejection fraction 20%
CASE 6

PMH
Hypertension for 9 years; history of gout

FH
Father and mother both alive with no history of CHD or
diabetes.

SH
Works as a computer programmer and sits at his desk most of the day; does not exercise on
a regular basis; drinks alcohol (2 to 3 beers) mainly on the weekends while watching sports
on TV

Meds
Aspirin 80 mg once daily
Verapamil SR 180 mg once daily

ROS
No chest pain, shortness of breath, or dizziness

PE
VS: BP 142/86 mm Hg, pulse 71 beats per minute, respiratory
rate 16 beats per minute, temperature 37°C (98.6°F),
waist circumference 38 inches (96.52 cm)
CV: RRR, normal S1, S2; no murmurs, rubs, or gallops
Abd: Soft, non-tender, non-distended; positive for bowel
sounds, no hepatosplenomegaly or abdominal aortic
aneurysm
Exts: Ankle-brachial index 1.1
Neck: No carotid and basilar bruits

Labs
- Total cholesterol 256 mg/dL (6.63 mmol/L),
- Triglycerides 235 mg/dL (2.66 mmol/L),
- HDL cholesterol 27 mg/Dl (0.70 mmol/L),
- glucose 115 mg/dL (6.38 mmol/L),
- all other labs within normal limits