Examine this patient's eyes.

Examine this patient's fundus.

History

· Usually no ocular symptoms.

· History of hypertension.

Examination (Fig. 77)

· Arteriovenous nipping.

· Arteriolar narrowing.

· Macular star.

· Flame-shaped and blot haemorrhages.

· Cottonwool exudates.

· Papilloedema may or may not be present.

Proceed as follows:

Tell the examiner that you would like to:

· Check the blood pressure.

· Examine the urine for proteinuria.

· Examine the heart for left ventricular hypertrophy.

This patient has flame-shaped haemorrhages with a macular star (lesions) due to

hypertension (aetiology).

How would you grade hypertensive retinopathy?

Keith-Wagner-Barker classification (Am J Med Sci 1939; 197: 33243):

· Stage I - arteriolar narrowing.

· Stage Il - irregular calibre of arterioles.

· Stage III - cottonwool exudates; flame and blot haemorrhages, retinal oedema.

· Stage IV - papilloedema.

Note. Subsequent studies have shown that the clinical features and prognosis of

patients with stage III and stage IV disease were similar whether or not papillo-edema

was present; consequently the terms 'malignant' and 'accelerated' can be used

interchangeably (BMJ 1986; 292: 235-7; Q J Med 1993; 86: 485-93). Instead,

'hypertensive crisis' is used to refer to the syndrome of raised blood pressure

com-plicated by end-organ damage (e.g. stroke, renal failure, myocardial ischaemia or

infarction, stage Ill or IV hypertensive retinopathy).

Mention some causes of cottonwool spots (Lancet 1965: i.' 303).

· HIV infection per se.

· Anaemias.

· Infective endocarditis.

· Leukaemias.

· Diabetic retinopathy (see pp 518-23).

Mention a few causes of hypertension.

· In 90% of cases it is essential hypertension with no underlying cause, and this

may represent the 'normal' spread.

· In 10% of cases there is an underlying cause:

-renal causes : renal artery stenosis, polycystic kidneys, chronic glomerulo-nephritis,

polyarteritis nodosa, chronic pyelonephritis.

Endocrine causes: Cushing's syndrome, Conn's syndrome, phaeochromocytoma,

acromegaly, diabetes mellitus.

- Eclampsia and pre-eclamptic toxaemia of pregnancy.

- Coarctation of the aorta.

How would you investigate a patient with hypertension?

· Urine for protein, glucose, casts.

· Mid-stream urine for microscopy and culture.

· Urea and electrolytes, fasting lipids.

· CXR.

· ECG.

· Urine catecholamines.

· Intravenous pyelography.

· Renal artery digital subtraction angiography (DSA).

How would you treat hypertension ?

· Salt restriction.

· Drug therapy.

· First line (BMJ 1990; 301: 1172):

-In women and smokers - bendrofiumethiazide (bendrofluazide).

-In non-smoking men - beta-blockers.

· Advise the patient to stop smoking.

Sir C.T. Dollery, was Dean of the Royal Postgraduate Medical School, Hammersmith

Hospital, London; his interests include clinical pharmacology, hypertension and medical

education.

John Swales, contemporary Professor of Medicine, Leicester; his chief interest is

hypertension.

James C. Petrie, Professor and Head of Medicine and Therapeutics, Aberdeen; his

interests included hypertension and cardiovascular prevention. He was also the

President of the Royal College of Physicians of Edinburgh.