Hypertension
 
click here for “In the Clinic”  Hypertension

Here are a few common clinical scenarios that you probably encounter several times a week.  Your job now is to say what you would do in these situations and why.  In extreme detail.  Detail the parts of your recommendation which stand on firm evidence base and the parts which stand on shaky or non-existent evidence.  Secondary sources such as the In the Clinic article attached here, UptoDate, The Hopkins module, and The Cochrane reviews are good places to start your research.  However, your presentation should refer to important primary studies and not just quote recommendations or guidelines. 

Question 1

The patient is a 65 year-old man with a history of hypercholesterolemia (treated with Zocor) who has had BP of 150-160/90-100 on several measurements taken over the course of the year that you’ve seen him.  Every time he comes he adds that he’s nervous, that he just had something salty to eat, that he’s under stress, or something else.  Furthermore he says that he has his own blood  pressure cuff and that his home BP’s are 120/70-80.  He brought the cuff in once and you verified its accuracy.  Exam is otherwise normal.  Labs and EKG are normal.  Do you accept his readings and leave him untreated?  Is there any risk to pure “whitecoat” hypertension? 

Question 2

The patient is a 45 year-old African-American man you’ve been following for hypertension.  Blood pressures range from160-190/95-110 despite escalating doses of HCTZ (current dose 50mg), Atenolol (currently 100mg qd), Monopril (40Mg) and Adalat (90mg).  The Patient maintains that he takes his medicines consistently.  You’ve had a lot of doubts about this.  How do you assess his compliance?  If he is non-compliant, what are some of the possible reasons for it?  Are there any interventions that have been shown to reliably improve compliance?   

If, instead, you determine that he actually is compliant with his medications and his HTN is resistant, are there any other conditions that need to be ruled out?    What modifications (if any) would you make in his medication regimen?

 Question 3

The patient is a 65 year-old Caucasian woman you’ve been following for hypertension.  Blood pressures range from 170-200/100-110 despite escalating doses HCTZ (current dose 50 mg), Atenolol (100 mg), Monopril (40 mg) and nifedipine (120 mg).   Does the patient warrant a workup for secondary causes of hypertension?  What would this workup consist of?  What is the yield of such a workup?  Are there any validated clinical predictors which can help the clinician decide who should be evaluated for secondary hypertnesion?