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HTN CASE
 

                    HYPERTENSION

 

PATIENT PRESENTATION:

John Davis (J.D.) is a 52-year-old American man, who complains of a throbbing headache in the morning for the past week. He was diagnosed with hypertension 6 years ago and was initially treated with lifestyle modifications, and then with antihypertensive medication (amlodipine). He took this medication for 2 years and then discontinued it because he did not think it was needed. Past medical history is unremarkable. J.D.'s father had hypertension and died of an MI at age 54. His mother had diabetes and hypertension and died of a stroke at age 68.

J.D. has been married for 20 years and has two sons who are healthy. He  smokes 1 pack per day of cigarettes (for 35 years) .He occasionally drinks alcohol (1-2 drinks per week).He thinks that his BP is high because of job-related stress. He does not believe that he has hypertension. J.D. states that he does not engage in any regular form of exercise and does not restrict his diet in any way.

Physical examination shows he is 69” tall, weighs 108 kg (BMI 35.2 kg/m2)

BP is 148/88 mm Hg (left arm) and 150/86 mm Hg (right arm) while sitting, heart rate is 82 beats/min and regular, Temp . 37.1oC .

One month ago, his BP values were 152/88 mm Hg and 154/84 mm Hg. Funduscopic examination reveals mild arterial narrowing, arteriovenous nicking, with no exudates or hemorrhages. The remainder of the physical examination is essentially normal.

 

Laboratory examination:

K 4.0 mEq/L

Na 143 mg/L

Cl 101 mg/L

BUN  24 mg/dL

SrCr  1.3 mg/dL

glucose 95 mg/dL

uric acid 8.0 mg/dL

ALT 28U/L

AST 35U/L

 

Fast Lipid Profile

LDL 140 mg/dL

HDL 35 mg/dL

TG 230 mg/dL

TC 198 mg/dL

 

UA:Yellow, Clear, pH 5.5, (-) protein, (-) glucose, (-) ketones, (-) blood, (-) nitrite , no bacteria

 

ECG and chest radiograph reveal mild LVH.

 

QUESTIONS:

Problem Identification

a.       What is the proper assessment of J.D.'s hypertension based on this information?

b.      Based on the guidelines from JNC VII ,classify this patient's hypertension.?

c.       Why is J.D.at high risk for hypertension-related complications?

d.      What forms of target organ damage are present in J.D.?

 

Desired Outcome:

a.       List the goals of treatment for this patient.

 

Optimal Plan:

a.       Outline specific lifestyle modification for this patient.

b.      Which treatment principles need to be considered when choosing an initial antihypertensive agent for J.D.?

 

Follow-up Question

a.       Suppose the patient now complains of intolerable adverse effects due to the current antihypertension drug therapy. Outline an appropriate change to her current therapy.

b.      Suppose the patient is tolerating the current drug therapy but has not achieved the desired Bp control. Outline an appropriate change to her current therapy.

 

Patient Education

 

a.       What information about hypertension, and antihypertensive therapy you should  provide to this patient.?

b.      Describe how you would explain to a patient how to use sphygmomanometer?

 

 

Outline the change ,if any you would make to the phrmacotherapeutic regimen for this patient if he had present at the initial visit with each of the following characteristics:

·        African-American descent

·        10 year history of asthma

·        History of angina pectoris

·        Diabetes mellitus

·        A pregnant woman 

 

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