On history taking patient gives no history of any medical problems and that she seems fine. She smokes about 10 cigarettes a day and does not drink. She has a strong family history of high blood pressure with her mother and elder sister on medications and her father died a few years ago due to stroke. On examination the patient is overweight with a BMI of 28.
Vitals: BP = 175/95 mmHg , H/R = 78/min, R/R = 14/min , Temp = 98.6 F
The patient brings with her a chest x ray which was done a few weeks ago when she had some cough. the x ray is shown below:
How will you approach this patient?
Hypertension is a common medical problem. The initial approach in managing this patient should be
directed towards confirming the diagnosis of hypertension (i.e to ensure there is no element of ‘white coat’ hypertension) and, if hypertension
is confirmed, treating the blood pressure. This should then be followed by an assessment of whether there are secondary causes for her hypertension, followed by advice and management of her other vascular risk factors (her weight and smoking) and a decision regarding prescription of the OCP.
What is the Differential Diagnosis of High Blood pressure in this patient?
- Essential hypertension - the most common cause
- False elevation as a result of inadequate BP cuff size
- Isolated clinic (‘white coat’) hypertension
- Renal hypertension
- Renovascular hypertension
- Primary hyperaldosteronism (Conn’s syndrome)
- Phaeochromocytoma
- Coarctation of the aorta
- Cushing’s syndrome
- Acromegaly - very rare in above mentioned case
- Polycystic ovarian syndrome
Clinical Features in patients With Hypertension:
1. Hypertension is usually asymptomatic until there is progression to end-organ damage.
2. Some patients, on being given a diagnosis of hypertension, will ascribe many different and varied
complaints to it. A multitude of symptoms, eg headache, epistaxis, tinnitus, dizziness and fainting, are often blamed on an elevated BP, but probably occur with similar frequency in those whose BP is normal.
3. It is important to elicit any potential complications of untreated hypertension.
4. Hypertension initially results in
left ventricular hypertrophy (LVH), followed by diastolic and finally systolic left ventricular dysfunction, a history of shortness of breath on exertion or at rest, indicated pulmonary edema.
5. Episodes of weakness in any of the limbs, or problems with speech or eyesight indicates transient ischemic attacks or a stroke.
What things are important to consider while investigating a patient with high blood pressure?
When investigating the patient with hypertension consider the following:
• Is there a secondary cause?
• Is there evidence of end-organ damage?
Mention a list of investigations that would be helpful for this patient?
1. ECG: Look particularly for evidence of Left Ventricular Hypertrophy.
2. Urine : Check for proteinuria and haematuria using dipsticks. If positive for protein, quantification of albumin/creatinine ratio with a spot urine or 24-hour collection is required. The presence of proteinuria and/or haematuria would be consistent with the patient having a renal disorder with secondary hypertension, or with renal damage caused by hypertension.
3. Blood tests :Check CBC, electrolytes, renal and liver function, uric acid, fasting glucose and lipid profile.
4. Chest radiograph: (was normal as shown above) Assess heart size and look for pulmonary oedema and possible (but very unlikely) radiographic signs of coarctation of aorta.
5. Echocardiography : This is more sensitive than ECG at detecting LVH.
6. Ambulatory blood pressure monitoring: may be needed to confirm the diagnosis and exclude
‘white coat’ hypertension, the latter being suspected particularly in cases where BP recorded in clinic is very high but there seems to be no evidence of end-organ damage.
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