Question

Hypertension

E.W. is a 40-year-old African American male, who has had difficulty controlling his HTN lately.

He is visiting his primary care provider for a thorough physical examination and to renew a

prescription to continue his blood pressure medication.

PMH

• Chronic sinus infections

• Hypertension for approximately 11 years

• Pneumonia 6 years ago that resolved with antibiotic therapy

• One major episode of major depressive illness caused by the suicide of his wife of 15 years,

5 years ago

• No surgeries

FH

• Father died at age 49 from AMI; had HTN

• Mother has DM and HTN

• Brother died at age 20 from complications of CF

• Two younger sisters are A&W

SH

The patient is a widower and lives alone. He has a 15-year-old son who lives with a maternal

aunt. He has not spoken with his son for four years. The patient is an air traffic controller

at the local airport. He smoked cigarettes for approximately 10 years but stopped

smoking when he was diagnosed with HTN. He drinks “several beers every evening to relax”

and does not pay particular attention to the sodium, fat, or carbohydrate content of the

foods that he eats. He admits to “salting almost everything he eats, sometimes even before

tasting it.” He denies ever having dieted. He takes an occasional walk but has no regular

daily exercise program.

Patient Case Question 1. Identify six risk factors for hypertension in this patient’s

history.

Meds

• Hydrochlorothiazide 50 mg po QD

• Pseudoephedrine hydrochloride 60 mg po q6h PRN

• Beclomethasone dipropionate 1 spray into each nostril q6h PRN

Patient Case Question 2. Why is the patient taking hydrochlorothiazide and what is the

primary pharmacologic mechanism of action of the drug?

Patient Case Question 3. Why is the patient taking pseudoephedrine hydrochloride and

what is the primary pharmacologic mechanism of action of the drug?

Patient Case Question 4. Why is the patient taking beclomethasone dipropionate and

what is the primary pharmacologic mechanism of action of the drug?

All

Rash with penicillin use

ROS

• States that his overall health has been fair to good during the past 12 months

• Weight has increased by approximately 20 pounds during the last year

• Denies chest pain, shortness of breath at rest, headaches, nocturia, nosebleeds, and

hemoptysis

• Reports some shortness of breath with activity, especially when climbing stairs, and that

breathing difficulties are getting worse

• Denies any nausea, vomiting, diarrhea, or blood in the stool

• Self-treats occasional right knee pain with OTC extra-strength acetaminophen

• Denies any genitourinary symptoms

Patient Case Question 5. What is the most clinically significant information related to

HTN in this review of systems?

Physical E xam and Lab Tests

Gen

The patient is an obese black man in no apparent distress. He appears to be his stated age.

Patient Case Table 5.1 Vital Signs

Average BP 155/96 mm Hg (sitting) Ht 5!11"

HR 73 and regular Wt 221 lb

RR 15 and unlabored BMI 31.0

T 98.8°F

Vital Signs

See Patient Case Table 5.1

Patient Case Question 6. Identify the two most clinically significant vital signs relative

to this patient’s HTN.

HEENT

• TMs intact and clear throughout

• No nasal drainage

• No exudates or erythema in oropharynx

• PERRLA, pupil diameter 3.0 mm bilaterally

• Sclera without icterus

• EOMI

• Funduscopy reveals mild arteriolar narrowing with no nicking, hemorrhages, exudates, or

papilledema

Patient Case Question 7. What is the significance of the HEENT examination?

Neck

• Supple without masses or bruits

• Thyroid normal

• (#) lymphadenopathy

Lungs

• Mild basilar crackles bilaterally

• No wheezes

Heart

• RRR

• Prominent S3 sound

• No murmurs or rubs

Patient Case Question 8. Which abnormalities in the heart and lung examinations may

be related and why might these clinical signs be related?

Abd

• Soft and ND

• NT with no guarding or rebound

• No masses, bruits, or organomegaly

• Normal BS

Rectal/GU

• Normal size prostate without nodules or asymmetry

• Heme (#) stool

• Normal p e n i s and testes

Ext

• No CCE

• Limited ROM right knee

Neuro

• No sensory or motor abnormalities

• CNs II–XII intact

• Negative Babinski

• DTRs $ 2%

• Muscle tone $ 5/5 throughout

Patient Case Question 9. Are there any abnormal neurologic findings and, if so, might

they be caused by HTN?

Laboratory Blood Test Results

See Patient Case Table 5.2

Patient Case Table 5.2 Laboratory Blood Test Results

Na 139 meq/L RBC 5.9 million/mm3 Mg 2.4 mg/dL

K 3.9 meq/L WBC 7,100/mm3 PO4 3.9 mg/dL

Cl 102 meq/L AST 29 IU/L Uric acid 7.3 mg/dL

HCO3 27 meq/L ALT 43 IU/L Glu, fasting 110 mg/dL

BUN 17 mg/dL Alk phos 123 IU/L T. cholesterol 275 mg/dL

Cr 1.0 mg/dL GGT 119 IU/L HDL 31 mg/dL

Hb 16.9 g/dL T. bilirubin 0.9 mg/dL LDL 179 mg/dL

Hct 48% T. protein 6.0 g/dL Trig 290 mg/dL

Plt 235,000/mm3 Ca 9.3 mg/dL PSA 1.3 ng/mL

Patient Case Question 10. Why might this patient’s GGT be abnormal?

Patient Case Question 11. Identify three other clinically significant lab tests above.

Patient Case Table 5.3 Urinalysis

Appearance Clear and amber in color Microalbuminuria (%)

SG 1.017 RBC 0/hpf

pH 5.3 WBC 0/hpf

Protein (#) Bacteria (#)

Urinalysis

See Patient Case Table 5.3

Patient Case Question 12. What is the clinical significance of the single abnormal

urinalysis finding?

ECG

Increased QRS voltage suggestive of LVH

ECHO

Moderate LVH with EF $ 46%

Patient Case Question 13. What is the likely pathophysiologic mechanism for LVH

in this patient?

Patient Case Question 14. What does the patient’s EF suggest?

Answer 1

ANSWER :

1) Six risk factors of hypertension in this patient :

• Gender : Prevalence of hypertension is more in males than females
• Strong family history of hypertension : Father and mother
• Chronic depressive illness
• Smoking
• High salt intake
• No regular physical activity

2)Patient taking hydrochlorothiazide for hypertension.

• It is a diuretic
• Hydrochlorithiazide ------> increase the loss of salt and water through urine -----> decreases plasma volume and extracellular fluid -------> decreases venous return -------> decreases cardiac output ------> decreases blood pressure

3) Patient taking pseudoephedrine hydrochloride for chronic sinus infection.

• It is a decongestant
• Psuedoephedrine ------> acts on alpha adrenergic receptors in mucosa of respiratory tract ------> vasoconstriction -----------> decreases edema and nasal congestion -------> air flows freely in nasal sinuses ------> improves nasal airway patency and can breath freely
• Pseudoephedrine ------> acts on beta adrenergic receptors ------> relaxation of smooth muscles in bronchi -----> opens airways ----> breath freely

4) Patient taking Beclomethasone diproprionate for chronic sinus infection.

• It is a corticosteroid
• Beclomethasone diproprionate -------> decreases inflammation and swelling in nasal sinuses -----> reduces pressure in sinuses by draining the mucus -----> decreases the pain

5) Significant information regarding HTN in review of systems :

• Increase in weight by 20 pounds during last one year
• Worsening of shortness of breath with activity like climbing of stairs

6)Significant vital signs :

• Blood pressure : 155/96 (elevated)
• BMI : 31 ( Moderate obesity)