Questions for Discussion:

  1. What additional questions regarding past medical history are important to ask? Answer
  2. What portions of the physical examination are essential in the evaluation of this patient? Answer

Further history reveals that the patient's mother developed chronic hypertension when she was 45 years old.   The remainder of the history is unrevealing and the physical examination discloses no abnormalities.   Repeat blood pressure at the end of the physical examination is 144/100 mmHg.

  1. What might explain the elevated blood pressure other than chronic hypertension? Answer
  2. What is your management plan at this stage and why? Answer

Over the next two months several blood pressure readings by the office nurse average 150/96 mmHg.

  1. What is your diagnosis at this point? Answer
  2. What would you tell the patient at this point regarding his blood pressure? Answer
  3. What laboratory tests would you order and why?   Answer
  4. How would you approach the management of this patient's elevated blood pressure? Answer
  5. What is your goal for this patient's blood pressure and why? Answer

After two months blood pressure multiple blood pressure determinations average 144/94 mmHg. LDL is 140 mg/dL. The EKG suggests LVH.

  1. How would you treat his hypertension now? Justify your choice. Answer
  2. Select an initial antihypertensive agent, including dose, for each of the following patients. (Note: there is no one correct answer but be prepared to justify your choice).  Answer
    1. An 85 y.o. women with a persistently elevated BP of 185 / 85 mmHg.
    2. A 35 y.o. male, world class bicycle racer with asthma and a persistently elevated BP of 152/98 mmHg.
    3. A   50 y.o. African-American female advertising executive with stable angina and a BP of 150/90 mmHg.            
    4. A   74 y.o. Caucasian male with moderate prostatism and a BP = 170/100 mmHg.
  3. For each of the following antihypertensives:  a) estimate the cost to the patient for a   month's supply purchased at a community based pharmacy; and b) list the most common adverse effects (symptoms, signs, laboratory abnormalities) with which the prescribing physician should be familiar. Answer
    1. hydrochlorothiazide 25 mg per day
    2. hydrocholorothiazide 25/triamterene 37.5 (Dyzaide; Maxide) 1 tablet per day
    3. atenolol   50 mg per day
    4. metoprolol extended release (Toprol XL) 50 mg per day
    5. captopril 50 mg twice per day
    6. lisinopril (Zestril; Prinivil) 10 mg per day
    7. losartan (Cozaar) 50 mg per day
    8. diltiazem long acting (Cardizem CD) 120 mg per day
    9. nifedipine long-acting (Procardia XL) 30 mg per   day
    10. terazosin (Hytrin) 5 mg per day
  4. What is the absolute reduction in risk of stroke that can be attributed to drug therapy?
  5. How many patients with mild-moderate hypertension must be treated for 5 years in order to prevent one stroke (number needed to treat= NNT)?
  6. You decide to begin drug therapy for presumed essential hypertension. What agent and dose would you select for this patient and why?
  7. Describe the mode of antihypertensive action and most common, clinically significant, adverse effects for following classes of antihypertensive agents:
    1. Diuretics
    2. Beta-blockers
    3. Calcium channel blockers
    4. Angiotensin converting enzyme inhibitors