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Common Congenital Heart Lesions - page 58 / 126





58 / 126

58 of 126

Summary and plan of action for patient with suspected hypertension

  • --

    because HTN is usually asymptomatic, screening is essential. (cheap, effective, etc.)

    • 1)

      several elevated blood pressures on multiple occasions in various settings (avoid white coat phenomenon.)

    • 2)

      First thing to do is rule out secondary causes of HTN.

      • a.

        What is my patient’s age: are they older than 50 or younger than 20?

      • b.

        Is the elevated BP very very high?

      • c.

        Does my patient have family members with HTN?

      • d.

        Is the patient taking any drugs that could cause an elevation in BP, such as oral contraceptives?

      • e.

        Does she have an abdominal bruit on exam?

      • f.

        Does she have adequate blood flow to her legs?

      • g.

        Does she have urine catecholamines, excess aldosterone, hypokalemia, urine cortisol or a ROUND FACE?

    • 3)

      If the above questions do NOT bring results, exclude secondary HTN and cautiously think about ESSENTIAL HTN

    • 4)

      Next, you need to think about treatment plans

    • 5)

      Is the patient experiencing any symptoms from her HTN?

      • a.

        Make sure she is not in a hypertensive crisis

      • b.

        Assess any organ damage

        • i.

          Does she ever have symptoms of CAD?

        • ii.

          Does she have an abdominal aortic aneurysm?

        • iii.

          Ask her about her kidney function

        • iv.

          Check her retinas for signs of PAPILLEDEMA (unlikely) or increased light reflection (?)

    • 6)

      Counsel patient on lifestyle

      • a.

        Does she smoke? She should not.

      • b.

        Can she lose some weight?

      • c.

        What are her exercise habits?

      • d.

        Discuss caffeine, relaxation therapy and alcohol

    • 7)

      After all that, you can begin to think about treating your patient with drugs. Keep in mind the goals of therapy: lower BP in order to prevent the consequences of elevated blood pressure. (I think. I made this up.)

    • 8)


      • a.

        Diuretics: recall that diuretics work by decreasing volume, thereby lowering MAP and CO. They should not be used in persons with kidney problems. There are several kinds of diuretics; most promote Na and Cl excretion.

      • b.

        Beta blockers: lower BP by decreasing HR and CTY; decrease renin secretion which causes a decrease in TPR. (Recall that Ang II is a vasoconstrictor)

    • 9)

      There are other drugs to choose from is our patient is unresponsive or suffers from side effects. Always keep in mind the patient’s specific needs and age. Remember the age-related changes in hypertension and pick your drugs accordingly.

    • 10)

      If you choose more than one drug, make sure that the multiple drugs together act at different sites and do not oppose each other.

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