Hypertension Case Discussion

Hypertension Case
Chief Complaint
• The chief complaint is a brief statement of the reason why the
patient consulted the physician, stated in the patient’s own
words. In order to convey the patient’s symptoms accurately,
medical terms and diagnoses are generally not used. The
appropriate medical terminology is used after an appropriate
evaluation (i.e., medical history, physical examination,
laboratory and other testing) leads to a medical diagnosis.
Chief Complaint
• “I just moved to town, and I’m here to see my new
doctor for a checkup. I’m just getting over a cold. Overall,
I’m feeling fine, except for occasional headaches and
some dizziness in the morning. My other doctor
prescribed a low-salt diet for me, but I don’t like it!”
• The history of present illness is a more complete description
of the patient’s symptom(s). Usually included in the HPI are:
• Date of onset
• Precise location
• Nature of onset, severity, and duration
• Presence of exacerbations and remissions
• Effect of any treatment given
• Relationship to other symptoms, bodily functions, or activities
(e.g., activity, meals)
• Degree of interference with daily activities
• Sam Street is a 62-year-old African-American male who
presents to his new family medicine physician for evaluation
and follow-up of his medical problems. He generally has no
complaints, except for occasional mild headaches and some
dizziness after he takes his morning medications.
• He states that he is dissatisfied with being placed on a low
sodium diet by his former primary care physician. He reports a
“usual” chronic cough and shortness of breath, particularly
when walking moderate distances (states, “I’m just out of
• The past medical history includes serious illnesses,
surgical procedures, and injuries the patient has
experienced previously. Minor complaints (e.g.,
influenza, colds) are usually omitted unless they might
have a bearing on the current medical situation.
• Hypertension × 15 years
• Type 1 diabetes mellitus
• Chronic obstructive pulmonary disease, Stage 2 (Moderate)
• Benign prostatic hyperplasia
• Chronic kidney disease
• The family history includes the age and health of parents,
siblings, and children. For deceased relatives, the age
and cause of death are recorded. In particular, heritable
diseases and those with a hereditary tendency are noted
(e.g., diabetes mellitus, cardiovascular disease,
malignancy, rheumatoid arthritis, obesity).
• Father died of acute MI at age 71. Mother died
of lung cancer at age 64. Mother had both HTN
and DM.
• The social history includes the social characteristics of
the patient as well as the environmental factors and
behaviors that may contribute to the development of
disease. Items that may be listed are the patient’s marital
status; number of children; educational background;
occupation; physical activity; hobbies; dietary habits; and
use of tobacco, alcohol, or other drugs.
• Former smoker (quit 3 years ago; smoked 1 ppd × 28 years);
reports moderate amount of alcohol intake. He admits he has
been nonadherent to his low sodium diet (states, “I eat
whatever I want.”) He does not exercise regularly and is
limited somewhat functionally by his COPD. He is retired and
lives alone.
• The medication history should include an accurate record of the
patient’s current use of prescription medications,
nonprescription products, and dietary supplements. Because
pharmacists possess extensive knowledge of the thousands of
prescription and nonprescription products available, they can
perform a valuable service to the health care team by obtaining
a complete medication history that includes the names, doses,
routes of administration, schedules, and duration of therapy for
all medications, including dietary supplements and other
alternative therapies.
• Triamterene/hydrochlorothiazide 37.5 mg/25 mg po Q AM
• Insulin 70/30, 24 units Q AM, 12 units Q PM
• Doxazosin 2 mg po Q AM
• Albuterol INH 2 puffs Q 4–6 h PRN shortness of breath
• Tiotropium DPI 18 mcg 1 capsule INH daily
• Salmeterol DPI 1 INH BID
• Entex PSE 1 capsule Q 12 h PRN cough and cold symptoms
• Acetaminophen 325 mg po Q 6 h PRN headache
• Allergies to drugs, food, pets, and environmental factors
(e.g., grass, dust, pollen) are recorded. An accurate
description of the reaction that occurred should also be
included. Care should be taken to distinguish adverse
drug effects (“upset stomach”) from true allergies
• PCN—Rash
• In the review of systems, the examiner questions the patient
about the presence of symptoms related to each body system.
In many cases, only the pertinent positive and negative findings
are recorded. In a complete ROS, body systems are generally
listed by starting from the head and working toward the feet
and may include the skin, head, eyes, ears, nose, mouth and
throat, neck, cardiovascular, respiratory, gastrointestinal,
genitourinary, endocrine, musculoskeletal, and neuropsychiatric
• The purpose of the ROS is to evaluate the status of each
body system and to prevent the omission of pertinent
information. Information that was included in the HPI is
generally not repeated in the ROS.
• Patient states that overall he is doing well and just getting
over a cold. He has noticed no major weight changes over
the past few years. He complains of occasional
headaches, which are usually relieved by acetaminophen,
and he denies blurred vision and chest pain. He states
that his shortness of breath is “usual” for him, and that
his albuterol helps.
• He denies experiencing any hemoptysis or epistaxis; he
also denies nausea, vomiting, abdominal pain, cramping,
diarrhea, constipation, or blood in stool. He denies
urinary frequency, but states that he used to have
difficulty urinating until his physician started him on
doxazosin a few months ago.
Physical Examination
• The exact procedures performed during the physical
examination vary depending upon the chief complaint and the
patient’s medical history. In some practice settings, only a
limited and focused physical examination is performed. In
psychiatric practice, greater emphasis is usually placed on the
type and severity of the patient’s symptoms than on physical
findings. A suitable physical assessment textbook should be
consulted for the specific procedures that may be conducted
for each body system. The general sections for the PE are
outlined as follows:
• Gen (general appearance)
• VS (vital signs)—blood pressure, pulse, respiratory rate,
and temperature.
• In hospital settings, the presence and severity of pain is
included as “the fifth vital sign, weight and height are
included in the vital signs section here, but they are not
technically considered to be vital signs.
• Skin (integumentary)
• HEENT (head, eyes, ears, nose, and throat)
• Lungs/Thorax (pulmonary)
• Cor or CV (cardiovascular)
• Abd (abdomen)
• Genit/Rect (genitalia/rectal)
• MS/Ext (musculoskeletal and extremities)
• Neuro (neurologic)
• WDWN, African-American male; moderately
overweight; in no acute distress.
• WDWN = Well-developed, well-nourished.
• BP 168/92 mm Hg (sitting; repeat 170/90), HR 76 bpm
(regular), RR 16 per min, T 37°C; Wt 95 kg, Ht 6'2'‘
BP = Blood Pressure.
HR = Heart rate.
Bpm = beat per minute.
RR = Respiratory rate.
T = Temperature.
Wt = Weigt
Ht= Hight
• TMs clear; mild sinus drainage; AV nicking noted;
no hemorrhages, exudates, or papilledema.
• TM = Tympanic membrane.
• AV = arteriovenous
• Supple without masses or bruits, no thyroid enlargement or
• Lung fields CTA bilaterally. Few basilar crackles, mild expiratory
• wheezing
• RRR; normal S1 and S2. No S3 or S4
• RRR = Regular rate and rhythm.
• S = Sound.
• Soft, NTND; no masses, bruits, or organomegaly.
Normal BS.
• NTND = Non-tender/non-distended.
• BS = Bowel sounds; breath sounds or blood
• Enlarged prostate; benign
• No CCE.
• CCE = Clubbing, cyanosis, edema
• No gross motor-sensory deficits present. CN II–
XII intact. A & O × 3.
• CN II–XII = Cranial Nerves 2 to 12.
• A & O × 3 = Awake and oriented to person, place,
and time.
• Yellow, clear, SG 1.007, pH 5.5, (+) protein, (–)
glucose, (–) ketones, (–) bilirubin, (–) blood, (–)
nitrite, RBC 0/hpf, WBC 1–2/ hpf, . neg bacteria,
1–5 epithelial cells.
• Hpf = High Power Field.
• SG = Specific gravity.
• Normal sinus rhythm
ECHO (6 months ago):
• Mild LVH, estimated EF 45%:
• LVH = Left ventricular hypertrophy.
• EF = Ejection fraction.
1. Hypertension, uncontrolled
2. Type 1 diabetes mellitus, controlled on current
insulin regimen
3. Moderate COPD, stable on current regimen
4. BPH, symptoms improved on doxazosin
Problem Identification
• 1.a. Create a list of this patient’s drug-related
problems, including any medications which may
be contributing to the patient’s uncontrolled
• Significant - Monitor Closely
• triamterene + albuterol
• triamterene increases and albuterol decreases serum potassium.
Effect of interaction is not clear, use caution. Significant - Monitor
• triamterene + salmeterol
• triamterene increases and salmeterol decreases serum
potassium. Effect of interaction is not clear, use caution.
Significant - Monitor Closely.
• albuterol + salmeterol
• albuterol and salmeterol both decrease serum potassium.
Significant - Monitor Closely.
• albuterol + hydrochlorothiazide
• albuterol and hydrochlorothiazide both decrease serum
potassium. Significant - Monitor Closely.
• salmeterol + hydrochlorothiazide
• salmeterol and hydrochlorothiazide both decrease serum
potassium. Significant - Monitor Closely.
• albuterol + salmeterol
• albuterol and salmeterol both decrease sedation.
Significant - Monitor Closely.
• albuterol + salmeterol
• albuterol and salmeterol both increase sympathetic
(adrenergic) effects, including increased blood pressure
and heart rate. Significant - Monitor Closely.
• albuterol + hydrochlorothiazide
• albuterol, hydrochlorothiazide. Mechanism:
pharmacodynamic synergism. Minor or non-significant
interaction. Hypokalemia.
• salmeterol + hydrochlorothiazide
• salmeterol, hydrochlorothiazide. Mechanism:
pharmacodynamic synergism. Minor or non-significant
interaction. Hypokalemia.
• hydrochlorothiazide + insulin glargine
• hydrochlorothiazide decreases effects of insulin glargine by
pharmacodynamic antagonism. Minor or non-significant
interaction. Thiazide dosage >50 mg/day may increase blood
Problem Identification
• 1.b. How would you classify this patient’s HTN (e.g.,
Prehypertension, Stage 1, or Stage 2), according to JNC 7
• 1.c. What are the patient’s known cardiovascular risk factors,
and what is the patient’s Framingham risk score?
• 1.d. What evidence of target organ damage or clinical
cardiovascular disease does this patient have?
Framingham Risk score
• http://hp2010.nhlbihin.net/atpiii/calculator.asp
Desired Outcome
• 2. List the goals of treatment for this patient
(including the patient’s goal blood pressure,
according to JNC 7 Guidelines).
Therapeutic Alternatives
• 3.a. What lifestyle modifications should be
encouraged for this patient to achieve and
maintain adequate blood pressure reduction?
Therapeutic Alternatives
• 3.b. What reasonable pharmacotherapeutic options are
available for controlling this patient’s blood pressure, and
what comorbidities and individual patient considerations
should be taken into account when selecting
pharmacologic therapy for his HTN? How might Mr.
Street’s HTN medications potentially affect his other
medical problems?
Optimal Plan
• 4.a. Outline specific lifestyle modifications for this
• 4.b. Outline a specific and appropriate
pharmacotherapeutic regimen for this patient’s
uncontrolled hypertension, including drug(s), dose(s),
dosage form(s), and schedule(s).
Outcome Evaluation
• 5. Based on your recommendations, what parameters
should be monitored after initiating this regimen and
throughout the treatment course? At what time intervals
should these parameters be monitored?
Patient Education
• 6. Based on your recommendations, provide
appropriate education to this patient.

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