58 of 126
Summary and plan of action for patient with suspected hypertension
because HTN is usually asymptomatic, screening is essential. (cheap, effective, etc.)
several elevated blood pressures on multiple occasions in various settings (avoid white coat phenomenon.)
First thing to do is rule out secondary causes of HTN.
What is my patient’s age: are they older than 50 or younger than 20?
Is the elevated BP very very high?
Does my patient have family members with HTN?
Is the patient taking any drugs that could cause an elevation in BP, such as oral contraceptives?
Does she have an abdominal bruit on exam?
Does she have adequate blood flow to her legs?
Does she have urine catecholamines, excess aldosterone, hypokalemia, urine cortisol or a ROUND FACE?
If the above questions do NOT bring results, exclude secondary HTN and cautiously think about ESSENTIAL HTN
Next, you need to think about treatment plans
Is the patient experiencing any symptoms from her HTN?
Make sure she is not in a hypertensive crisis
Assess any organ damage
Does she ever have symptoms of CAD?
Does she have an abdominal aortic aneurysm?
Ask her about her kidney function
Check her retinas for signs of PAPILLEDEMA (unlikely) or increased light reflection (?)
Counsel patient on lifestyle
Does she smoke? She should not.
Can she lose some weight?
What are her exercise habits?
Discuss caffeine, relaxation therapy and alcohol
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.)
FIRST LINE DRUGS FOR UNCOMPLICATED HTN:
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.
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)
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.
If you choose more than one drug, make sure that the multiple drugs together act at different sites and do not oppose each other.