\n
Think about this again the gentleman has now had three separate readings showing high blood pressure<\/p>\n<\/div><\/div>\n<\/div><\/div>\n\n\n\n
<\/p>\n\n\n\n
Do you think that he needs a 24 hour Ambulatory BP monitor?<\/strong><\/p>\n\n\n\n\n
Yes<\/button>\n
In an ideal world every patient with BP readings <180\/120 should be referred for ambulatory blood pressure monitoring. If this cannot be carried out for whatever reason, home blood pressure readings are acceptable. It is thought that they are more representative than clinic readings where there may be an element of “white coat hypertension”.<\/p>\n<\/div><\/div>\n\n\n\n
No<\/button>\n
Clinical reality means that often ambulatory BP testing cannot be undertaken. In this case we have three unequivocal elevated values. If they were more equivocal we may be more concerned to ensure ambulatory BP testing takes place.<\/p>\n\n\n\n
As you can see from above there is no clear right or wrong answer. NICE guidance does advise ambulatory readings.<\/p>\n\n\n\n
<\/p>\n<\/div><\/div>\n<\/div><\/div>\n\n\n\n
What details do you think are important to find out from the patient?<\/strong><\/p>\n\n\n\n <\/p>\n\n\n\n
\n
Does he have a history of high BP and has it ever been checked before?<\/button>\n
True. Yes this is very important. Although a lot of patients will be asymptomatic and found out at routine screens, like this man. A man of his age may have had a BP check in the recent past and this will help in determining if this is an acute rise in BP or more chronic problem<\/p>\n<\/div><\/div>\n\n\n\n
Does he have pounding headaches?<\/button>\n
False. No this is not really that important. Although hypertension can cause headaches, this is rare and should not be considered and important symptom in hypertension. However, it is probably a question that one should ask as part of a systems review.<\/p>\n<\/div><\/div>\n\n\n\n
Does he have a heart murmur?<\/button>\n
False. No this is not really that important. Although some heart murmurs are associate with high pulse pressures, a heart murmur in someone with hypertension is probably an incidental finding.<\/p>\n<\/div><\/div>\n\n\n\n
How many ready meals does he eat?<\/button>\n
True. Yes, surprisingly. Processed food (ready meals, tinned food and cured meat products) generally contain a lot of salt and thus can be a major factor in contributing to hypertension<\/p>\n<\/div><\/div>\n\n\n\n
Does he have any other history of ischaemic heart disease or diabetes?<\/button>\n
True. Yes, these are very important co-morbidities that need to be considered in the treatment of hypertension.<\/p>\n\n\n\n
<\/p>\n\n\n\n
The most likely diagnosis for this gentleman is Primary\/ Essential hypertension<\/span><\/strong><\/p>\n<\/div><\/div>\n<\/div><\/div>\n\n\n\nWhat exacerbating factors are important in hypertension?<\/strong><\/p>\n\n\n\nSelect the correct answers<\/em><\/p>\n\n\n\n\n
Obesity<\/button>\n
True. There is a relationship between excess body fat and hypertension. Weight loss of 1kg results in approximately 1-2mmHg reduction in BP<\/p>\n<\/div><\/div>\n\n\n\n
Low Calcium intake<\/button>\n
False. According to NHANES III studies higher calcium intake is associated with lower rates of age-related increases of systolic BP<\/p>\n<\/div><\/div>\n\n\n\n
Low levels of exercise<\/button>\n
True. According to Whelton\u2019s studies, regular aerobic exercise is associated with reductions in both, systolic and diastolic blood pressure. It s suggested that people take 150mins of exercise a week.<\/p>\n<\/div><\/div>\n\n\n\n
Alcohol<\/button>\n
True. Alcohol has a hypertensive effect which develops within a few days of excessive intake and usually recedes within a few days of abstinence. Three or more standard drinks daily causes a threefold increase in the prevalence of mild hypertension (>140\/90mmHg). Patients should be encouraged to stick to safe limits.<\/p>\n<\/div><\/div>\n\n\n\n
Smoking<\/button>\n
False. Smoking a cigarette does lead to an acute increase of blood pressure but it only lasts for about 15 minutes. However, smoking increases CVD risk and thus patients should be encouraged to quit.<\/p>\n<\/div><\/div>\n\n\n\n
NSAIDs<\/button>\n
True. NSAIDs elevate BP approximately 5mmHg. Caution is advised if using NSAIDs as well as ACE inhibitors due to the possibility of renal impairment<\/p>\n<\/div><\/div>\n\n\n\n
Salt intake<\/button>\n
True. The current average intake of sodium in the UK is 3.2g, equivalent to about 8g of salt, which can lead to raised blood pressure. The recommended daily amount of sodium (in the UK) is 2.4g (equivalent to about 6g of salt).<\/p>\n\n\n\n
<\/p>\n<\/div><\/div>\n<\/div><\/div>\n\n\n\n
What symptoms\/signs of end organ damage should be sought?<\/strong><\/p>\n\n\n\nBlood in the urine<\/button>\n
No, except in malignant hypertension, or when kidney disease is causing high blood pressure. Not a consequence of essential hypertension.<\/p>\n<\/div><\/div>\n\n\n\n
Protein in the urine<\/button>\n
Maybe, although proteinuria is more likely to reflect underlying kidney disease than be a sign of end organ damage. A vicious cycle is set up so that high blood pressure worsens kidney disease.<\/p>\n<\/div><\/div>\n\n\n\n
Shortness of breath<\/button>\n
Yes, in prolonged hypertension, left ventricular hypertrophy can occur and this can go on to cause left ventricular impairment and pulmonary oedema.<\/p>\n<\/div><\/div>\n\n\n\n
Diabetes Mellitus<\/button>\n
No, though it may cause high blood pressure<\/p>\n<\/div><\/div>\n\n\n\n
Retinopathy<\/button>\n
Yes, surprisingly. Retinopathy (changes in the vessels in the retina) are some of the earliest signs of hypertensive end-organ damage and are subclassified into early (AV nipping) and late (retinal haemorrhage and papilloedema).<\/p>\n<\/div><\/div>\n\n\n\n
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