LAPORAN KASUS HIPERTENSI

Disusun oleh: Oktiyasari Puji Nurwati 207.121.0005 Dosen Pembimbing: dr. Rofika Hanifa, Sp.PD

KEPANITERAAN KLINIK MADYA LABORATORIUM ILMU PENYAKIT DALAM RSD MARDI WALUYO BLITAR FAKULTAS KEDOKTERAN UNIVERSITAS ISLAM MALANG 2012

IDENTITAS PENDERITA
Nama : Ny. P Umur : 59 tahun Jenis kelamin : Perempuan Pekerjaan : IRT Agama : Islam Alamat : Wiroyudan 4/4 Status Perkawinan : Menikah Suku : Jawa

 Keluhan Utama : Sakit kepala Riwayat Penyakit Sekarang : Pasien mengeluhkan sakit kepala sejak 5 jam yang lalu dan semakin lama semakin memberat. Sakit kepala terasa seperti tertimpa benda berat pada tengkuk. Sakit kepala terus-menerus. Sakit kepala meningkat bila beraktifitas dan menurun dengan beristirahat. Selain itu pasien juga mengeluhkan badan lemas sejak 5 hari ini.

 Riwayat Penyakit Dahulu Riwayat darah tinggi Riwayat sakit gastritis

: (+) : (+)

Riwayat Penyakit Keluarga Sakit darah tinggi (+) (Ayah) Riwayat Pengobatan : captopril Riwayat kebiasaan :waktu luang digunakan untuk nonton TV dan kadang- kadang melakukan pekerjaan rumah.

PEMERIKSAAN FISIK
Keadaan Umum Tampak sakit berat dan lemah, kesadaran compos mentis (GCS 456), status gizi kesan cukup. Tanda Vital TD : 190/110 mmHg N : 76 x / menit RR : 22 x /menit T : 36,3 oC BB : 48 kg

REVIEW OF SYSTEM
Kulit, kepala, mata, hidung, telinga, mulut, leher, thorak, abdomen, ekstremitas: normal

PEMERIKSAAN PENUNJANG
DARAH LENGKAP Hb Hitung leukosit LED Diff count Eritrosit Trombosit Hematokrit MCV/MCH/MCHC GDA kolesterol HDL LDL creatinin BUN HASIL 11,9 8.900 25-51 -/-/3/82/12/3 3.660.000 205.000 35,8 98,0/32,5/32,2 141 198 57 125 1,63 18 NILAI NORMAL P: 11,5-16; L: 13,5-18 g/dL 4000 11.000/cmm P: 0-20; L: 0-15 /jam 1-2/0-1/3-5/54-62/25-33/3-7 P: 3,0-6,0; L: 4,5-6,5 jt/cmm 150.000-450.000/cmm P: 35-47; L: 40-54 % 80-97 fl/27-31 pg/32-36 70-140 mg/dl <250 mg/dl L>55 mg/dl P>25 mg/dl <150 mg/dl L, 0,6-1,4 mg% P, 0,5-1,2 mg% 4,7-23,4 mg%

Uric Acid
Bilirubin tot Bilirubin direct SGOT

5,6
0,56 0,06 10

L 3,4-7,0 mg% P 2,5-6,0 mg%

1 mg% 0,25 mg% L, 37 u/l P, 31 u/l

SGPT

L: 40 u/l P:31 u/l

POMR

WORKING DIAGNOSA HT stage II

PENATALAKSANAAN
Non Medika mentosa Bedrest Diet rendah garam Medikamentosa IVFD : Infus RL 16 tpm Hydrocholorthiazide 25 mg-0-0 Captopril 3x 25 mg

DEFINISI
Tekanan Darah Tinggi (hipertensi) adalah suatu peningkatan tekanan darah di dalam arteri. Hipertensi didefinisikan oleh Joint National Committee on Detection,Evaluation and Treatment of High Blood Pressure (JIVC) sebagai tekanan yang lebih tinggi dari 140/90 mmHg

ETIOLOGI
HIPERTENSI PRIMER HIPERTENSI SEKUNDER Penyakit ginjal Kelainan hormonal Obat penyebab lain

KLASIFIKASI HIPERTENSI BERDASARKAN JNC 7

GEJALA KLINIS
sakit kepala kelelahan mual muntah sesak nafas gelisah pandangan menjadi kabur (yangterjadi karena adanya kerusakan pada otak, mata, jantung dan ginjal)

DIAGNOSIS
Pengukuran tekanan darah Retina oftalmoskopi retinopati Jantung ECG pembesaran jantung Ginjal UL, USG, atau rontgen Ginjal. Pemeriksaan dengan stetoskop menandakan adanya bruit.

Algorithm for Treatment of Hypertension

Lifestyle Modifications
Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease)

Initial Drug Choices

Without Compelling Indications With Compelling Indications

Stage 1 HTN (SBP 140159 or DBP 9099 mmHg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination.

Stage 2 HTN (SBP >160 or DBP >100 mmHg) 2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB)

Drug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed.

Not at Goal Blood Pressure

Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist.

JNC 7 Express. JAMA. 2003 Sep 10; 290(10):1314

MODIFIKASI GAYA HIDUP

Physiologic Components of BP
Heart HR

Veins

Stroke Volume

Arteries SVR

Thiazide Diuretics
Veins Mechanism: menghambat Na/K pumps di tubulus distal Examples:

Hydrocholorthiazide 12.5-25 mg daily

Thiazides

Chlorthalidone 12.5-50 mg d aily

Loop Diuretics
Veins Mechanism: Inhibit Na/K/Cl ATPase in ascending loop of henle Examples:

Furosemide 20 mg BID
Administer AM and lunch time to avoid nocturia

Thiazides Loops

Aldosterone Receptor Antagonists

Veins Mechanism: inhibit aldosterones effect at the receptor, reducing Na and water retention Examples:

Spironolactone 25 mg daily

Thiazides Loops Aldosterone Ant.

Am J Hypertension. 2003; 16:925-930.

Nitrates
Veins Mechanism: Direct venodilation by release of nitric oxide Examples:

Isosorbide dinitrate 10 mg TID

Thiazides Loops Aldosterone Ant. Nitrates

IMDUR 30 mg daily

ACEI & ARBs

Veins

Mechanism: Inhibit vasoconstriction by inhibiting synthesis or blocking action of angiotensin II; provides balanced vasdilation Examples:

Enalapril 2.5-40 mg daily BID

Thiazides Loops Aldosterone Ant. Nitrates ACEI ARB

Lisinopril 5 40 mg daily Irbesartan 150-300 mg daily

Losartan 25-100 mg Daily - BID

Beta Blockers
Heart

Mechanism: Competitively inhibit the binding of catecholamines to beta-adrenergic receptors Examples:

Atenolol 25-100 mg PO daily Metoprolol 25 -100 mg PO daily or BID Carvedilol 6.25-25 mg PO BID

Beta Blockers

Diltiazem and Verapamil

Heart Mechanism: Decrease calcium influx into cells of vascular smooth muscle and myocardium Examples:

Diltiazem 60-480mg q6h to daily

Beta Blockers Diltiazem Verapamil

Verapamil 60-480 q8h to daily

Monitor: HR Verapamil causes constipation Relatively contraindicated in heart failure

Alpha2 Agonists: Central Acting Agents

Heart

Mechanism: false neurotransmitters reduce sympathetic outflow reducing sympathetic tone

Examples:

Clonidine 0.1-0.6 mg PO BID-TID; patch

Beta Blockers Diltiazem Verapamil Via Central Mechanism: Clonidine

Methyldopa, Guanabenz, Guanfacine

Monitor: HR Side effects often limiting: Dry mouth, orthostasis, sedation

Dihydropyridine Calcium Channel Blockers

Arteries Mechanism: Decrease calcium influx into cells of vascular smooth muscle Examples:

Dihydropyridine CCBs

Amlodipine 2.5-10 mg PO daily Felodipine2.5-10 mg PO daily Do not use immediate release nifedipine
Monitor: Peripheral edema, HR (can cause reflex tachycardia)

Vasodilators
Arteries

Mechanism: Direct vasodilation of arterioles via increased intracellular cAMP Examples:

Hydralazine 20-400 mg BID-QID

Minoxidil 2.5-40 mg PO daily-BID

Dihydropyridine CCBs Hydralazine Minoxidil

Monitor: HR (can cause reflex tachycardia), Na/Water retention Hydralazine is an alternative in HF if ACEI contraindicated

Alpha1 Blockers
Arteries

Mechanism: Inhibit peripheral post-synaptic alpha1 receptors causing vasodilation Examples:

Terazosin 1 20 mg daily
Doxazosin 1 16 mg daily

Dihydropyridine CCBs Hydralazine Minoxidil Alpha1 Blockers

Cause marked orthostatic hypotension, give dose at bedtime Consider only as add on therapy Can be beneficial in patients with BPH

Pharmacologic Sites of Action

Veins Heart Arteries

Thiazides Loops Aldosterone Ant. Nitrates ACEI ARB

Beta Blockers Diltiazem Verapamil Via Central Mechanism: Clonidine

Dihydropyridine CCBs Hydralazine Minoxidil Alpha1 Blockers ACEI ARB

TERIMA KASIH

Compelling Indications for Individual Drug Classes

Compelling Indication Heart failure Initial Therapy Options THIAZ, BB, ACEI, ARB, ARA Clinical Trial Basis ACC/AHA Heart Failure Guideline, MERIT-HF, COPERNICUS, CIBIS, SOLVD, AIRE, TRACE, ValHEFT, RALES ACC/AHA Post-MI Guideline, BHAT, SAVE, Capricorn, EPHESUS

Postmyocardial infarction

BB, ACEI

High CAD risk

THIAZ, BB, ACEI, CCB

ALLHAT, HOPE, ANBP2, LIFE, CONVINCE

Compelling Indications for Individual Drug Classes

Compelling Indication Diabetes Initial Therapy Options ACEI, ARB, CCB, THIAZ, BB, ACEI, ARB Clinical Trial Basis NKF-ADA Guideline, UKPDS, ALLHAT

Chronic kidney disease

NKF Guideline, Captopril Trial, RENAAL, IDNT, REIN, AASK

Recurrent stroke prevention

THIAZ, ACEI

PROGRESS