الضغط العالى (hypertention)و الالتهاب الرئوي (pneumonia)

SYSTEMIC HYPERTENSION
Definition:
Persistent elevation of Blood pressure> 140/90 mmHg diagnosed as 
hypertension.
Types:
1. Essential hypertension:
Age: 35-55 with +ve family history without apparent cause.
Diastolic blood pressure > 90 mm Hg, this is usually associated with elevated 
systolic blood pressure.
Theories of primary hypertension:
1. Renal Theory: There is increase of renin secretion.
2. Increased adrenal gland activity.
3. Increased activity of 
sympathetic discharge.
4. Genetic factors.
5. Obesity.
2. Secondary hypertension:
Age: usually < 35 or> 55 years. Family history is usually negative.
Causes of secondary hypertension:

3. Renal artery stenosis.
4. Polycystic kidney disease.
Endocrinal:
1. Cushing syndrome.
2. Hyperparathyroidism. 
Pregnancy: Preeclampsia. 
Drugs: Corticosteroids.
Oral contraceptives.
Examination
1. Asymptomatic.
2. Occipital headache.
3. Blurring of vision.
Complications: (Target organ damage)
1. Heart
- Ischemic heart disease.
- Atrial fibrillation.
2. Neurological
- Stroke (cerebral hemorrhage - Lacunar infarction).
- Hypertensive encephalopathy.
3. Kidney
- Renal failure.
4. Eye
- Retinopathy.
5. Side effects of the antihypertensive drugs.
Investigations:
1. ECG & X-ray (Left ventricular hypertrophy)."Long standing hypertension"
2. Echo cardiography (Left ventricular hypertrophy).
3. Fundus Examination If it is positive, this indicates long standing hypertension 
(Haemorrhage – exudate).
4. Investigations for the Cause:
• Urine analysis for protein (Albuminuria).
• Kidney function tests.
• Cortisol level (Cushing $).
• Lipid profile.
Treatment:
1. Life style modification: (Non Pharmacological therapy).
* Avoid stressful conditions.
* Avoid straining.
2. Diet
* Salt restriction, take much fruits and vegetables. .
* Low fatty diet (to decrease cholesterol).

Low carbohydrate diet (to decrease body weight).
* Weight reduction (BMI < 25).
3. Drug Therapy

…………………………………………………………………………………………….

Pneumonia:

Definition.
Inflammatory reaction within the alveoli leading to exudation into alveoli then 
consolidation.
Predisposing factors:
1. Pneumococcal pneumonia often, follows influenza infection.
2. Cigarette smoking.
3. COPD.
4. Immunosuppression.
5. Aspiration with decreased conscious level.
6. Hospitalized ill patient.
It is helpful to consider pneumonia in two ways. Whether it developed at home 
(community-acquired) or in a hospital or institution (hospital acquired) or in 
immune compromised patient.Pathologically pneumonia can be classified 
according to the site of involvement of the lung into:
(a) Lobar pneumonia
In which there is involvement of a large portion of or an entire lobe of lung.
(b) Bronchopneumonia
It starts as infection of bronchi and bronchioles which is aspirated into the 
alveoli and result in wide spread patches of consolidation.
(A). Community Acquired Pneumonia
Definition:
Infection is usually spread by droplet inhalation; most patients 
affected are previously well, cigarette smokers.
C/P:
FAHM (toxemia) fever anorexia headache malaise.
• Dyspnea.
• Chest pain (pleurisy).
• Cough & expectoration of mucopurulant, rusty or blood stained sputum.
• Diminished movement, symmetrical chest Dullness.
• Crepitation Early: fine crepitation.
Late: coarse consonatingcrepitations.
The previous signs in cases of lobar pneumonia usually are limited to one lobe 
of the lung, but the signs are usually bilateral and patchy and usually in lower 
lobes in cases of bronchopneumonia.
Investigations:
1- X- ray: Homogenous opacity of a large portion of or an entire lobe of lung in 
case of lobar pneumonia or bilateral patchy, consolidation often affecting both 
lower lobes in case of bronchopneumonia.
2- Culture & Sensitivity for sputum.
3- Blood picture: TLC increase (bacterial infection). ESR increased. 
4- Blood gases showing hypoxia.
Un-resolving pneumonia:

This means active pneumonia in spite of antibiotic therapy for 2 weeks or more:
1. Immune compromised.
2. T.B.
3. Atypical pneumonia.
4. Resistant organism.
5. Bronchial carcinoma.
Treatment:
Generally, pneumonia is better treated with parenteral antibiotics, and then we 
start oral antibiotics, the duration of treatment is usually not less than 2 weeks.
1- Antibiotic therapy for pneumococcal and streptococcal pneumonia.
• Penicillin G injection. 1-2 gm. /6hours LV.
• (Klacid) 500 mg.
• Ampicillin or Amoxicillin.
2- Expectorant K iodides.
3- Chest pain NSAID (for pleurisy).
(B) Pneumonia in immune-compromised Patients.
Pulmonary infection is common in patients under immunosuppressive drugs.
Common causes of immune suppression
• DM.
• TB.
• Malignancy.
• Corticosteroid
s.
Treatment
• It is based on the etiological diagnosis.
• We can start with a third generation cephalosporin or a quinolone plus 
antistaph antibiotic, or meronam or tienam. This treatment is thereafter tailored 
according to the results of investigations.
(C) Nosocomial pneumonia
It is hospital acquired pneumonia in a patient who has been admitted for more 
than 
48 hours. The mortality is 30%.
Factors predisposing to nosocomial pneumonia:
(1) Reduced host defenses:
• Reduced immune defenses.
• Postoperativ
e reduced cough reflex.
(2) Aspiration of nasopharyngeal or gastric secretions:
• Reduced conscious level.
• Nasogastric intubation.
(3) Bacteria introduced into lower respiratory tract:
• Endotracheal intubation.
• Tracheostomy.
• Infected ventilators, nebulizers, bronchoscopes.

Bacteremia:
• Abdominal sepsis.
• I.V cannula infection.
C/P and investigations:
The clinical features and investigations are very similar to community acquired 
pneumonia.
Treatment:
• Third generation cephalosporin e.g. (cefotaxime) plus an aminoglycoside e.g. 
(Gentamicin).
• Aspiration pneumonia treated by co-amoxiclav (Augmentin) 1.2 gm. /8 
hrs.Plus metronidazole 500 mg/8 hrs.
• Physiotherapy, O2 therapy, fluid support.
Causes of recurrent pneumonia:
• Bronchial obstruction e.g. bronchial adenoma or carcinoma.
• Chronic lung diseases e.g. COPD.
• Recurrent aspiration e.g. in alcoholics, epileptics and severe 
gastroesophageal reflux.
• Immunodeficiency.
Complications of pneumonia:
1-
Post- pneumonic effusion.
2- Post pneumonic lung abscess. 
3- Meningoencephalitis.
4- Septic shock, multi organ failure

……………………اتمنى أن ينال رضاكم بالتوفيق ………….