Mr. U is a 48-year-old man with a BP of 165/90 mm Hg.
Mr. U’s BP is high. He has wanted to avoid taking medication and has been trying to watch his diet and lose weight. Both of his parents and several of his siblings have hypertension. His medical history is notable only for smoking 1 pack/day for 30 years; he does not use alcohol and takes no medications.
Mr. U’s review of symptoms is negative for chest pain, shortness of breath, claudication, headache, dizziness, palpitations, weight change, constipation, daytime sleepiness, and snoring. On physical exam, BP is 165/90 mm Hg in both arms; pulse, 84 bpm; RR, 16 breaths per minute. He weighs 220 pounds, with a body mass index (BMI) of 30 kg/m2. Fundoscopic exam shows some arteriolar narrowing with no hemorrhages or exudates. Jugular venous pressure is normal. Lungs are clear, and cardiac exam shows an S4 but no S3 or murmurs. There are no abdominal bruits; carotid, radial, femoral, posterior tibialis, and dorsalis pedis pulses are normal. There is no peripheral edema. Neurologic exam is normal.
Mr. U’s initial test results are as follows:
- ECG: Left ventricular hypertrophy by voltage, otherwise normal
- TSH, 1.0 microunit/mL
- Urine albumin–creatinine ratio: normal
- Na, 145 mEq/L; K, 4.2 mEq/L; Cl, 100 mEq/L; BUN, 11 mg/dL; creatinine, 0.5 mg/dL
- Fasting glucose, 90 mg/dL
- Fasting lipid panel: total cholesterol, 240 mg/dL; HDL, 40 mg/dL; triglycerides, 100 mg/dL; LDL, 180 mg/dL
Mr. U is counseled regarding smoking cessation and referred to a nutritionist for guidance regarding diet and exercise programs. He is started on hydrochlorothiazide, 12.5 mg daily, for his hypertension and atorvastatin, 40 mg daily, for his hypercholesterolemia (Table 23-6). One month later, his BP is 145/85 mm Hg. He has not yet started to exercise and has not quit smoking. You again counsel him regarding the importance of these lifestyle modifications and the possibility of avoiding a second medication if he exercises and loses weight. Six months later, after changing his diet and faithfully exercising 3 times a week, he has lost 5 pounds, and his BP is 135/82 mm Hg. He continues to smoke.
SOAP NOTE
S: 48 y/o man with a BP of 165/90 mmHg. He has been watching his diet to loose weight and trying to avoid medication. He doesn’t drink alcohol and doesn’t use medication, but has a family history of hypertension. Both of his parents and several siblings have hypertension. His past medical history includes smoking 1pack/day for 30 years. He denies chest pain, shortness of breath, claudication, headache, dizziness, palpitation, weight change, constipation, daytime sleepiness, and snoring.
O:
BP: 165/90 mmHg in both arms, Pulse 84 bpm, RR 16 breaths per minute
Weight: 220 lbs BMI: 30
Lungs are clear, cardiac exam shows S4, but no S3 or murmurs. Fundoscopic exam shows some arteriolar narrowing with no hemorrhages or exudates. Jugular venous pressure is normal. There are no abdominal bruits. Carotid, radial, femoral, posterior tibialis, and dorsalis perdis pulses are normal. There is no peripheral edema. Neurologic exam is normal.
Initial test results are:
ECG: Left ventricular hypertrophy by voltage, otherwise normal
TSH: 0.1 microunit/mL
Urine: albumin-creatinine ratio is normal
Na: 145 mEq/L K: 4.2 mEq/L Cl: 100 mEq/L BUN: 11 mg/dL
Creatinine: 0.5 mg/dL
Fasting glucose: 90 mg/dL
Fasting lipid panel: total cholesterol 240 mg/dL, HDL 40 mg/dL,
Triglyceride 100 mg/dL, LDL 180 mg/dL
A: Hypertension, Early Retinopathy, Hypercholesterolemia, Left ventricular hypertrophy, Obesity
R/O secondary hypertension
P: Smoking cessation counseling, refer to nutritionist for guidance regarding diet and exercise.
Hydrochlorothiazide 12.5 mg daily for hypertension.
Atorvastain 40mg daily for hypercholesterolemia
Summary: Hypertension can either be primary(essential) hypertension, or secondary (resulting from a specific identifiable cause). A family history of hypertension increases the pretest probability of essential hypertension. Patients between the ages of 20 and 50 have about twice the risk of developing primary hypertension if they have 1 first-degree relative with hypertension, the relative risk is 3-4 if 2 first-degree relatives have hypertension. Common condition that can contribute to primary hypertension include obesity, family history, and coexistent diabetes. Secondary hypertension is caused by endocrine diseases such as primary aldosteronism, phenchoromocytoma, thyroid disease, hyperparathyroidism, Cushing syndrome; or renal diseases such as chronic kidney disease, acute kidney injury, or vascular diseases such as renovasucluar disease, or pulmonary disease such as sleep apnea. Secondary hypertension can also be drug-induced or drug-related. Evaluation of patients with hypertension is to assess other cardiovascular risks and the presence or absence of target organ damage. In the absence of any of the clinical clues for secondary hypertension, it is unlikely that the patient has renal artery stenosis, hyperaldosteronism, or phenochromocytoma. Initial testing in a patient with hypertension and no clinical clues should include an ECG, electrolytes, BUN, creatinine, calcium, TSH, urine albumin–creatinine ratio, fasting glucose, and fasting lipid panel. Treatment is to reduce BP to recommended target, with systolic less than 140 mmHg and diastolic less than 90 mmHg. Lifestyle changes should also be initiated in all patients with hypertension. When selecting antihypertensive medications diuretics can be used as initial monotherapy. Lipid lowering should also be treated by statin therapy. Patient should also be counseled regarding exercise, diet, and smoking cessation.
