The sun rises over the San Joaquin Valley, California, today is August 7, 2020.
Have you heard any news about COVID-19? You surely have, who hasn’t? But above all the negativity surrounding this disease, including political issues, there is hope for the future. Have you heard of, for example, mRNA 1273?(1) Could this be the vaccine we have been waiting for? We don’t know yet, but there are more than 21 vaccines being tested right now around the world. If an effective vaccine is found, you’ll certainly hear about it in this podcast.
Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.
The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve.
Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971.
“Everything can be taken from a man but one thing: the last of the human freedoms—to choose one’s attitude in any given set of circumstances, to choose one’s own way.”― Viktor E. Frankl
I am Dr Velazquez Amador, I am originally from Jalisco, Mexico where I was born and race. I completed my medical studies at the Universidad of Guadalajara, and now I on the third year of FM residency.
I learned about a patient whom had an incomplete work up for adrenal insufficiency but still treated. He ended up showing signs of Cushing’s syndrome and resistant hypertension. I want to talk about secondary hypertension and Primary Aldosteronism.
Why that knowledge important for you and your patients?
It is important because it reminds me that secondary causes of hypertension are often under diagnosed.
How did you get that knowledge?
Reading upon new cases, specially from the inpatient population, it often leads me to find new differentials and new testing modalities.
Where did that knowledge come from?
First line review data place for me is Uptodate now that I am in residency. But the initial knowledge came while on Medical school. Reading physiology and physiopathology books. The book that I like to consult a lot is Kelly’s Essentials for Internal Medicine, this book chapters encompass anatomy, physiology and the pathology aspect beside diagnoses and treatment. It is very complete. While in residency, also my reference is the AAFM articles.
Disorder | Suggestive clinical features |
General |
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Renovascular disease |
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Primary kidney disease |
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Drug-induced hypertension:
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Pheochromocytoma |
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Primary aldosteronism | Unexplained hypokalemia with urinary potassium wasting; however, more than one-half of patients are normokalemic |
Cushing's syndrome |
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Sleep apnea syndrome | Common in patients with resistant hypertension, particularly if overweight or obese Loud snoring or witnessed apneic episodes Daytime somnolence, fatigue, and morning confusion |
Coarctation of the aorta |
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Hypothyroidism |
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Primary hyperparathyroidism |
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Primary Aldosteronism
The evaluation of a patient with hypertension depends upon the likely cause and the degree of difficulty in achieving acceptable blood pressure control since many forms of secondary hypertension lead to "treatment-resistant" hypertension. Because it is not cost effective to perform a complete evaluation for secondary hypertension in every hypertensive patient, it is important to be aware of the clinical clues that suggest secondary hypertension. There are a number of general clinical clues that, in isolation or in combination, are suggestive of secondary hypertension. Primary aldosteronism is a hormonal disorder that leads to high blood pressure. It occurs when your adrenal glands produce too much of a hormone called aldosterone.
The classic presenting signs of primary aldosteronism are hypertension and hypokalemia, but potassium levels are frequently normal in modern-day series of primary aldosteronism. The presence of primary mineralocorticoid excess should be suspected in any patient with the triad of hypertension, unexplained hypokalemia, and metabolic alkalosis. However, most patients with primary mineralocorticoid excess are normokalemic and, rarely, some are hypokalemic but normotensive (primarily in young adult females).
The most common subtypes of primary aldosteronism are:
The presence of primary mineralocorticoid excess should be suspected in any patient with the triad of hypertension, unexplained hypokalemia, and metabolic alkalosis.
In patients diagnosed with primary aldosteronism, treatment of the mineralocorticoid excess results in reversal or improvement of the hypertension and resolution of the increased cardiovascular risk.
Who should be tested?
Test for primary aldosteronism in the following patients:
●Hypertension and spontaneous or low-dose, diuretic-induced hypokalemia
The following patients should undergo testing even if they are normokalemic:
●Severe hypertension (>150 mmHg systolic or >100 mmHg diastolic) or drug-resistant hypertension (defined as suboptimally controlled hypertension on a three-drug program that includes an adrenergic inhibitor, vasodilator, and diuretic)
●Hypertension with adrenal incidentaloma
●Hypertension with sleep apnea
●Hypertension and a family history of early-onset hypertension or cerebrovascular accident at a young age (<40 years)
●All hypertensive first-degree relatives of patients with primary aldosteronism
Case-detection testing with measurement of plasma aldosterone concentration (PAC) and renin (plasma renin activity [PRA] or plasma renin concentration [PRC])
The test is performed by measuring a morning (preferably 8 AM), ambulatory, paired, random PAC and PRA or PRC.
The PRA and PRC are typically very low (due in part to the associated mild volume expansion) in patients with primary aldosteronism.
The PAC is usually >15 ng/dL (416 pmol/L), but may be as low as 10 ng/dL (277 pmol/L).
Some clinicians calculate a PAC/PRA ratio as part of the case detection strategy, but we prefer to use the paired random PAC and PRA (or PRC). The mean value for the PAC/PRA ratio in normal subjects and patients with primary hypertension (formerly called "essential" hypertension) is 4 to 10, compared with more than 30 to 50 in most patients with primary aldosteronism
In general, a PAC/PRA ratio greater than 20 (depending upon the laboratory normals) is considered suspicious for primary aldosteronism, although others use a cutoff criterion of 30.
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Speaking Medical: Xanthochromia
by Isabelo Bustamante, MS3
Have you seen the word xanthochromia in a Cerebrospinal Fluid (CSF) study result? Xanthochromia has a Greek origin combining “yellow” (xantho) and “color” (chromia). Xanthochromia basically meansyellowish-colored CSF that can be seen with the naked eye. CSF is normally crystal clear. Xanthochromia can be found after several hours of bleeding into the subarachnoid space. This is because of the degradation of red blood cells after Subarachnoid Hemorrhage or SAH. Now you know the medical word of the week, xathochromia. Have a nice week.
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Espanish Por Favor: Azúcar
by Dr Claudia Carranza
Hi this is Dr Carranza on our section Espanish Por Favor. This week’s word is azúcar. The word azúcar was made popular by the famous Cuban singer Celia Cruz; she used it as an expression of happiness and joy “AZÚCAR!”
Azúcar is a sweet crystalline substance derived from many plants such as sugar cane and sugar beet. You guessed it! Azúcar means sugar in Spanish. Azúcar is a substance that is part of us as humans and it literally runs through our veins.
Azúcar comes from the Hispanic Arabic assúkkar. Azúcar is a vital word to use when talking to patients with diabetes and obesity. Most people will understand blood glucose if you say just azúcar, but if you see a weird look in your patient you may be more specific with the phrase azúcar en la sangre.
Azúcar alta means high sugar (hyperglycemia), and azúcar baja means low sugar (hypoglycemia).
Now you know the Espanish word of the week, “AZÚCAR”, I hope you have a sweet day full of joy and happiness! Until next time!
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Now we conclude our episode number 22 “Salty and Sweet: Hypertension and Diabetes”. We covered the basics on Primary Aldosteronism with Dr Velazquez, the salty part: sodium and potassium; and Continuous Glucose Monitoring with Denise, the sweet part: sugar. Isabello explained xanthochromia, which is yellowish cerebrospinal fluid, and, to put the cherry on this salty and sweet cake, Dr Carranza taught that sugar in Spanish is azúcar.
This is the end of Rio Bravo qWeek. We say good bye from Bakersfield, a special place in the beautiful Central Valley of California, United States, a land where growing is happening everywhere.
If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice.
Our podcast team is Hector Arreaza, Gina Cha, Claudia Carranza, Roberto Velazquez, and the special participation of our medical students Isabelo Lucho Bustamante and Denise Le DeWhitt. Audio edition: Suraj Amrutia. See you soon!
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