Hypertension

8 Hypertension



Instruction


This patient has hypertension; would you like to examine her?



Salient features



History




• Chest pain or shortness of breath


• Intermittent claudication


• Headaches or visual disturbances (in accelerated or severe hypertension)


• Family history of hypertension


• Ask about hypertension during pregnancy


• Ask about medications.



Examination


Look for aetiology:



• Comment on Cushingoid facies if present


• Look for radiofemoral delay of coarctation of aorta


• Examine BP in both upper arms (the arm with the higher BP is used for serial follow-up of patients)


• Listen for renal artery bruit of renal artery stenosis and feel for polycystic kidneys.


Look for target organ damage (heart, kidney, nervous system, eyes:



• Palpate the apex for left ventricular hypertrophy


• Look for signs of cardiac failure


• Examine the fundus for changes of hypertensive retinopathy (see Case 238)


• Tell the examiner that you would like to check urine for protein (renal failure) and sugar (associated diabetes): increases risk of cardiovascular disease.



Diagnosis


This patient has retinopathy (lesion) caused by hypertension, which is probably renovascular (aetiology) as evidenced by the renal artery bruit. She probably has damage to other target organs (functional status).



Questions




How would you record the BP?


Use a device whose accuracy has been validated and one that has been recently calibrated.



Patient should be seated with the arm at the level of the heart. The BP cuff should be appropriate for the size of the arm and the cuff should be deflated at 2 mm/s and the diastolic BP is measured to the nearest 2 mmHg. Diastolic BP is recorded as disappearance of the sounds (phase V).


At least two recordings of BP should be made during at least two subsequent clinic visits where BP is assessed under the best conditions available.



What are the causes of BP discrepancy between the arms or between the arms and legs?




• Coarctation of aorta (p. 117)


• Patent ductus arteriosus (p. 108)


• Dissecting aortic aneurysm


• Arterial occlusion or stenosis of any cause


• Supravalvular aortic stenosis (see p. 34)


• Thoracic outlet syndrome.



How would you investigate a patient with hypertension in outpatients?


In patients without established cardiovascular disease, assess cardiovascular risk. Investigation should aim to identify diabetes, evidence of hypertensive damage to the heart and kidneys, and secondary causes of hypertension such as kidney disease:



• Full blood count (FBC)


• Urine for sugar, albumin and specific gravity


• Urea, electrolytes and serum creatinine


• Fasting lipids, fasting blood sugar, serum uric acid


• Serum total cholesterol to high density lipoprotein (HDL) cholesterol ratio


• ECG


• Chest radiograph


• 24-h urine collection to measure vanillyl mandelic acid.



What are the indications for ambulatory blood pressure recording?




• When clinic BP shows unusual variability (it allows detection of patients who are truly hypertensive but office BP measurements are normal—the patients with ‘masked’ hypertension).


• Hypertension is resistant to drug treatment with three or more agents.


• When symptoms suggest that the patient may have hypotension.


• To exclude ‘white-coat hypertension’.



What are causes of hypertension?




• Unknown or idiopathic (in 90% of cases)


• Renal: glomerulonephritis, diabetic nephropathy, renal artery stenosis, pyelonephritis


• Endocrine: Cushing syndrome, steroid therapy, phaeochromocytoma


• Others: coarctation of aorta, contraceptives, toxaemia of pregnancy.

Related posts:

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  3. Abnormal gait
  4. Dystrophia myotonica

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Dec 4, 2016 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Hypertension

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