Hypertension Case Study

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!”

HPI• 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

HPI

• 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

shape”).

PMH

• 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.

PMH

• Hypertension × 15 years

• Type 1 diabetes mellitus

• Chronic obstructive pulmonary disease, Stage 2 (Moderate)

• Benign prostatic hyperplasia

• Chronic kidney disease

FH

• 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).

FH

• Father died of acute MI at age 71. Mother died

of lung cancer at age 64. Mother had both HTN

and DM.

SH

• 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.

SH

• 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.

Meds:• 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.

Meds:

• 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

ALL:

• 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

(“hives”).

All

• PCN—Rash

ROS• 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

systems.

• 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.

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)

Gen:

• WDWN, African-American male; moderately overweight; in no acute distress.

• WDWN = Well-developed, well-nourished.

VS• 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

HEENT

• TMs clear; mild sinus drainage; AV nicking noted; no hemorrhages, exudates, or papilledema.

• TM = Tympanic membrane.

• AV = arteriovenous

Neck:• Supple without masses or bruits, no thyroid enlargement or

lymphadenopathy

Lungs:• Lung fields CTA bilaterally. Few basilar crackles, mild expiratory• wheezing

Heart:

• RRR; normal S1 and S2. No S3 or S4

• RRR = Regular rate and rhythm.

• S = Sound.

Abd:

• Soft, NTND; no masses, bruits, or organomegaly. Normal BS.

• NTND = Non-tender/non-distended.

• BS = Bowel sounds; breath sounds or blood sugar

Genit/Rect:• Enlarged prostate; benign

Ext:• No CCE.

• CCE = Clubbing, cyanosis, edema

Neuro:

• 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.

LABS:

UA:

• 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.

ECG• Normal sinus rhythm

ECHO (6 months ago):• Mild LVH, estimated EF 45%:

• LVH = Left ventricular hypertrophy.• EF = Ejection fraction.

Assessment:

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

hypertension.

DDIs:• Significant - Monitor Closely• triamterene + albuterol• triamterene increases and albuterol decreases serum potassium.

Effect of interaction is not clear, use caution. Significant - Monitor Closely.

• 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.

Minor• 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 glucose.

Problem Identification

• 1.b. How would you classify this patient’s HTN (e.g.,

Prehypertension, Stage 1, or Stage 2), according to JNC 7

Guidelines?

• 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 calculator

• 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

patient.

• 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.

Questions?