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I.

Introduction
1. CASE

A 56 year old man comes in for a routine health maintenance visit. He is new
to your practice and has no specific complains today. He has hypertension for which
he takes hydrochlorothiazide, and he occasionally takes an aspirin because someone
told him that it was good for his. He has no other significant medical story. He does
not smoke cirgarettes, occasionally drinks alcohol, and does not excrise. His father
died of a heart attack at age 60 years and his mother died at age 72 years of cancer.
He has two younger sisters who are in good health. On examination, his blood
pressure is 130/80 mmHg and his pulse is 75 bpm. He is 6 ft tall and weights 200 lb.
His complete physical examination is normal. You order a fasting lipid panel, which
subsequently retruns with the following results : total cholesterol 242 mg/dl;
triglycerides 138 mg/dl; hight-density lipoprotein (HDL) cholesterol 48 mg/dl; adn
low-density lipoprotein (LDL) cholesterol 155 mg/dl.
2. KEYWORD
a) A 56 year old man
b) Has hypertension for which he takes hydrochlorothiazide and
c)
d)
e)
f)
g)
h)
i)
j)
k)

occasionally takes an aspirin


He has no other significant medical story
He does not smoke cirgarettes
He occasionally drinks alcohol
Does not excrise
His father died of a heart attack
His mother died of cancer
Vital sign : blood pressure is 130/80 mmHg and his pulse is 75 bpm
He is 6 ft tall and weights 200 lb
Total cholesterol 242 mg/dl; triglycerides 138 mg/dl; hight-density
lipoprotein (HDL) cholesterol 48 mg/dl; adn low-density lipoprotein
(LDL) cholesterol 155 mg/dl.

3. TAKING NOTES
Surname
Firts name
Age
Sex
Marital Status
Occupation
Present Complaint
General Condition
ENT
RS
CVS Pulse
BP
GIS
GUS
CNS
Immadiate History
Point Of Note
Investigations
Diagnosis

II. DISCUSSION

1. Definition

No Name
56 years old
Male
No specific complaints, routine health
maintenance visit.
Normal
75 bpm
130/80 mmHg
He has hypertension
He
takes
hydrochlorothiazide
and
occasionally takes an aspirin
Total cholesterol 242 mg/dL, triglycerides
138 mg/dL, HDL 48mg/dL, LDL 155mg/dL
Hypertension

Hypertension was defined as persistent blood pressure where


systolic pressure above 140 mmHg and a diastolic pressure above 90 mmHg.
In the elderly population, hypertension is defined as systolic pressure of 160
mmHg and a diastolic pressure of 90 mmHg (Sheps, 2005).
2. Etiology
a) Primary (essential) hypertension
For most adults, there's no identifiable cause of high blood
pressure. This type of high blood pressure, called essential hypertension
or primary hypertension, tends to develop gradually over many years.
b) Secondary hypertension
Some people have high blood pressure caused by an underlying
condition. This type of high blood pressure, called secondary
hypertension, tends to appear suddenly and cause higher blood pressure
than does primary hypertension. Various conditions and medications can
lead to secondary hypertension, including:
1) Kidney problems
2) Adrenal gland tumors
3) Thyroid problems
4) Certain defects in blood vessels you're born with (congenital)
5) Certain medications, such as birth control pills, cold remedies, decongestants,
over-the-counter pain relievers and some prescription drugs
6) Illegal drugs, such as cocaine and amphetamines
7) Alcohol abuse or chronic alcohol use

8) Obstructive sleep apnea

3. Risk Factor
a) Hectic and stress filled life style
b) Unhealthy food habits
c) Obesity
d) Excessive consumption of liquors
e) Smoking
f) Over consumption of tea/coffee
g) Insufficient rest and sleep
h) Metabolic disorders
i) Hardening of the arteries
j) Excessive use of pain killers and other strong medicines
k) Genetic disorders
l) Over consumption of oily food and fast food
m) High salt intake
n) Emotional and Physical stress
o) Family history of hypertension
4. Clinical Manfiestasion
High blood pressure (HBP) it self usually has no signs or symptoms.
Rarely, headaches may occur. You can have HBP for years without knowing it.
During this time, the condition can damage your heart, blood vessels, kidneys,
and other parts of your body.

Some people only learn that they have HBP after the damage has caused
problems, such as coronary heart disease, stroke, or kidney failure.
And this clinical manifestasi usually the patient feels :
a)
b)
c)
d)
e)
f)
g)

gFuatioencrsf
oVnisprblem
Chestpain
Dyifcultnbreahg
gIruelahtb
oBndlthieur
Ponudgiyrchkest,a
Like symptoms, physical findings depend on the cause of hypertension,

its duration and severity, and the degree of effect on target organs.
a) Blood pressure - On initial examination, pressure is taken in both arms
and, if lower extremity pulses are diminished or delayed, in the legs to
exclude coarctation of the aorta. An orthostatic drop is present in
pheochromocytoma. Older patients may have falsely elevated readings by
sphygmomanometry because of noncompressible vessels. This may be
suspected in the presence of Osler's sign - a palpable brachial or radial
artery when the cuff is inflated above systolic pressure. Occasionally, it
may be necessary to make direct measurements of intra-arterial pressure,
especially in patients with apparent severe hypertension who do not
tolerate therapy.
b) Retinas - Narrowing of arterial diameter to less than 50% of venous
diameter, copper or silver wire appearance, exudates, hemorrhages, or
papilledema are associated with a worse prognosis.
c) Heart and arteries Left ventricular enlargement with a left ventricular
heave indicates severe or long-standing hypertrophy. Older patients
frequently have systolic ejection murmurs resulting from calcific aortic

sclerosis, and these may evolve to significant aortic stenosis in some


individuals. Aortic insufficiency may be auscultated in up to 5% of
patients, and hemodynamically insignificant aortic insufficiency can be
detected by Doppler echocardiography in 10-20%. A presystolic (S4)
gallop due to decreased compliance of the left ventricle is quite common
in patients with sinus rhythm.
d) Pulses - The timing of upper and lower extremity pulses should be
compared to exclude coarctation of the aorta. All major peripheral pulses
should be evaluated to exclude aortic dissection and peripheral
atherosclerosis, which may be associated with renal artery involvement.

5. Clasification Of Hipertension
There are two major types of hypertension and four less frequently found
types.
1. Primary or essential hypertension, that has no known cause, is diagnosed
in the majority of people.
2. Secondary hypertension is often caused by reversible factors, and is
sometimes curable.
The other types include:
a) Malignant Hypertension
This the most severe form of hypertension, is severe and
progressive. It rapidly leads to organ damage. Unless properly treated, it is
fatal within five years for the majority of patients. Death usually comes from
heart failure, kidney damage or brain haemorrhage. However, aggressive
treatment can reverse the condition, and prevent its complications. Malignant

hypertension is becoming relatively rare, and is not caused by cancer or


malignancy.
b) Isolated Systolic Hypertension
In this case the systolic blood pressure, (the top number), is
consistently above 160 mm Hg, and the diastolic below 90 mm Hg. This may
occur in older people, and results from the age-related stiffening of the
arteries. The loss of elasticity in arteries, like the aorta, is mostly due to
arteriosclerosis. The Western lifestyle and diet is believed to be the root cause.
Latest studies confirm the importance of treating ISH, as it
significantly reduces the incidence of stroke and heart disease. Treatment
starts with lifestyle modification, and if needed, added drugs.
c) White coat hypertension
Also called anxiety-induced hypertension, it means blood pressure is
only high when tested by a health professional. If confirmed, with repeat
readings outside of the clinical setting, or a 24-hour monitoring device, it does
not need to be treated. However, regular follow-up is recommended to ensure
that persistent hypertension has not developed.
Lifestyle changes like more exercise, less salt and alcohol, no nicotine
and weight loss, would be wise. A low fat, high fibre diet, with increased fruit
and vegetable intake, will be beneficial.
d) Resistant Hypertension
If blood pressure cannot be reduced to below 140/90 mmHg, despite a
triple-drug regime, resistant hypertension is considered.
Classification based of JNC 7 has introduced a new classification system
for hypertension.
a) Pre Hypertension - Systolic blood pressure (SBP) 120-139 mm Hg or diastolic
blood pressure (DBP) 80-89 mm Hg.
b) Stage I hypertension - SBP 140-159 mm Hg or DBP 90-99 mm Hg.

c) Stage II hypertension - SBP >160 mm Hg or DBP > 100 mm Hg.

6. Diagnosis
A. History
Ask about previous cardiovascular events because they often suggest an
increased probability of future events that can influence the choice of drugs for
treating hypertension and will also require more aggressive treatment of all
cardiovascular risk factors. Also ask patients if they have previously been told that
they have hypertension and, if relevant, their responses to any drugs they might have
been given.
Ask about Important previous events include : stroke or transient ischemic
attacks or dementia, coronary artery disease, including myocardial infarctions, angina
pectoris, and coronary revascularizations, Heart failure or symptoms suggesting left
ventricular dysfunction (shortness of breath, edema), Chronic kidney disease,
peripheral artery disease, diabetes and sleep apnea.
Ask about other risk factors. Thus, knowing about age, dyslipidemia,
microalbuminuria, gout, or family history of hypertension and diabetes can be
valuable. Cigarette smoking is a risk factor that must be identified so that counseling
can be given about stopping this dangerous habit.
Ask about concurrent drugs.
B. Physical Examination
1) Measuring blood pressure.
2) Document the patients weight and height and calculate body mass index.
3) Waist circumference.Why is this important?Independent of weight, this helps
determine whether a patient has the metabolic syndrome or is at risk for type 2

diabetes. Risk is high when the measurement is >102 cm in men or >88 cm in


women.
4) Signs of heart failure
5) Neurologic examination
6) Eyes examination
C. Investigation
1) Blood sample:
a) Electrolytes
b) Fasting glucose concentration
c) Serum creatinine and blood urea nitrogen
d) Lipid
e) Hemoglobin and hematocrit
f) Liver function test
2) Urine sample:
a) Albuminuria
b) Red and white cell
3) Electrocardiography
Other recommendations for diagnosing hypertension:
Eligible population
Patients at low risk of cardiovascular
events

Criteria
BP 140/90 mmHg or Higher at initial
visit and at two follow-up visits within 1
month of the initial visit.

Patients at increased risk of


cardiovascular events (e.g., patients with

BP 140/80 mm Hg or higher at initial

coronary heart disease, heart failure,

visit andat twofollow-up visits within 1

diabetes, chronic kidney disease, or

month of the initial visit.

history of stroke or TIA)


Suspect malignant hypertension

7. Treatment

systolic BP is higher than 210 and/or


diastolic BP is higher than 120.

For hypertension, the treatment goal for systolic blood pressure is usually
<140 mm Hg and for diastolic blood pressure <90 mm Hg. . It is important to inform
patients that the treatment of hypertension is usually expected to be a life-long
commitment and that it can be dangerous for them to terminate their treatment with
drugs or lifestyle changes without first consulting their practitioner.

A. Non pharmacologic treatment


Several lifestyle interventions have been shown to reduce blood pressure.
Apart from contributing to the treatment of hypertension, these strategies are
beneficial in managing most of the other cardiovascular risk factors
1) Weight loss, In patients who are overweight or obese, weight loss is
helpful in treating hypertension, diabetes, and lipid disorders.
Substituting fresh fruits and vegetables for more traditional diets may
have benefits beyond weight loss.
2) Salt reduction: High-salt diets are common in many communities.
Reduction of salt intake is recommended because it can reduce blood
pressure and decrease the need for medications in patients who are
salt sensitive, which may be a fairly common finding in black
communities.
3) Exercise: Regular aerobic exercise can help reduce blood pressure,
but opportunities to follow a structured exercise regimen are often
limited.
4) Alcohol consumption: Up to 2 drinks a day can be helpful in
protecting against cardiovascular events, but greater amounts of
alcohol can raise blood pressure and should therefore be discouraged.
In women, alcohol should be limited to 1 drink a day.

5) Cigarette smoking: Stopping smoking will not reduce blood pressure,


but since smoking by it self is such a major cardiovascular risk factor,
patients must be strongly urged to discontinue this habit.

B. Pharmacologic treatment
1) Angiotensin converting enzyme inhibitor
These agents reduce blood pressure by blocking the reninangiotensin system. They do this by preventing conversion of
angiotensin I to the blood pressureraising hormone angiotensin
II. They also increase availability of the vasodilator bradykinin
by blocking its breakdown.
Do not combine angiotensin receptor blockers with angiotensin
receptor blockers. Angiotensin-converting enzyme inhibitors
must not be used in pregnancy, especially in the second or third
trimesters, since they can compromise the normal development
of the fetus.
2) Angiotensin Receptor Blockers
Like angiotensin-converting enzyme inhibitors, antagonize the
reninangiotensin system. They reduce blood pressure by
blocking the action of angiotensin II on its AT1 receptor and thus
prevent the vasoconstrictor effects of this receptor.
When combined with either calcium channel blockers or
diuretics, they become equally effective in all patient groups. Do
not combine angiotensin receptor blockers with angiotensinconverting enzyme inhibitors.
Angiotensin receptor blockers must not be used in pregnancy,
especially in the second or third trimesters.
3) Thiazide and Thiazide-like Diuretics

These agents work by increasing excretion of sodium by the


kidneys and additionally may have some vasodilator effects.
Chlorthalidone has more powerful effects on blood pressure than
hydrochlorothiazide (when the same doses are compared) and
has a longer duration of action.
Diuretics are most effective in reducing blood pressure when
combined with angiotensin-converting enzyme inhibitors or
angiotensin receptor blockers, although they are also effective
when combined with calcium channel blockers.
4) Calcium Channel Blockers
These agents reduce blood pressure by blocking the inward flow
of calcium ions through the L channels of arterial smooth muscle
cells.
There are two main types of calcium channel blockers:
dihydropyridines, such as amlodipine and nifedipine, which
work by dilating arteries; and nondihydropyridines, such as
diltiazem and verapamil, which dilate arteries somewhat less but
also reduce heart rate and contractility.
5) Beta blockers
B-blockers reduce cardiac output and also decrease the release of
renin from the kidney. The combineda- and b-blocker, labetalol,
is widely used intravenously for hypertensive emergencies, and
is also used orally for treating hypertension in pregnant and
breastfeeding women.
6) A-Blockers
Reduce blood pressure by blocking arterial a-adrenergic
receptors and thus preventing the vasoconstrictor actions of these
receptors.

The a-blockers are effective in treating benign prostatic


hypertrophy, and so can be a valuable part of hypertension
treatment regimens in older men who have this condition.

7) Centrally Acting Agents


These drugs, the most well-known of which are clonidine and amethyldopa, work primarily by reducing sympathetic outflow
from the central nervous system.
In certain countries, including the United States, a-methyldopa is
widely employed for treating hypertension in pregnancy.
8) Direct Vasodilators
Because these agents, specifically hydralazine and minoxidil,
often cause fluid retention and tachycardia, they are most
effective in reducing blood pressure when combined with
diuretics and bblockers or sympatholytic agents. For this reason,
they are now usually used only as fourth-line or later additions to
treatment regimens.

9) Mineralocorticoid Receptor Antagonists


These agents can be effective in reducing blood pressure when
added to standard 3-drug regimens (angiotensin-converting
enzyme inhibitor or angiotensin receptor blocker/ calcium
channel
blocker/diuretic) in treatment-resistant patients. This may be
because aldosterone excess can contribute to resistant
hypertension.

8. Education
If you have high blood pressure, there are steps you can take to get it under
control, including:
a) Ask your doctor what your blood pressure should be: set a goal to lower your
pressure with your doctor then discuss how you can reach your goal. Work
with your health care team to make sure you meet that goal.
b) Take your blood pressure medication as directed: if you are having trouble,
ask your doctor what you can do to make it easier. For example, you may
want to discuss you medication schedule with you doctor if you are taking
multiple drugs at different times of the day. Or you may want to discuss side
effect you are feeling, or the cost of you medicine.
c) Quit smoking-and if you dont smoke, dont start: You can find tips and
resources at CDCs smoking and tobacco web site or Be Tobacco Free web
site.
d) Reduce sodium: Most American consume too much sodium, and it raises
blood pressure in most people.
The are other healthy habits, that can help keep your blood pressure under
control:
a) Achieve and maintain a healthy body weight.
b) Participate in 30 minutes of moderate physical activity on most days of the
week.
c) Eat a healthy diet that is high in fruits and vegetables and low in sodium,
saturated fats, trans fat, and cholesterol.
d) Manage stress

e) Limit the amount of alcohol you drink (no more than one drink each day for
women and two for men).
f) If you have high blood pressure and are prescribed medication, take it as
directed.
g) If you have a family member who has high blood pressure, you can help by
taking many of the steps listed above with them. Go for walks together or
cook meals with lower sodium.
h) Check your blood pressure regularly.

9.Complication
The excessive pressure on your artery walls caused by high blood pressure
can damage your blood vessels, as well as organs in your body. The higher you blood
pressure and the longer it goes uncontrolled, the greater the damage.
Uncontrolled high blood pressure can lead to :
a) Heart attack or stroke: high blood pressure can cause hardening and
thickening of the arteries (artherosclerosis), which can lead to a heart
attack, stroke or other complication.
b) Aneurysm: Increased blood pressure can cause your blood vessels to
weaken and bulge, forming an aneurysm. If an aneurysm ruptures, it can
be life-threatening.
c) Heart failure: To pump blood pressure can cause your blood vessels, your
heart muscle thickens. Eventually, the chickened muscle may have a hard
time pumping enough blood to meet you bodys needs, which can lead to
heart failure.
d) Weakened and narrowed blood vessels in your kidney: This can prevent
these organs from functioning normally.
e) Thickened, narrowed or torn blood vessels in the eyes: This can result in
vision loss.

f) Metabolic syndrome: This syndrome is a cluster of disorder of your bodys


metabolism, including increased waits circumference, high triglycerides:
low high-density lipoprotein (HDL): or good, cholesterol: high blood
pressure: and high insulin levels. If you have high blood pressure, youre
more likely to have other components of metabolic syndrome. The more
components you have, thee greater you risk of developing diabetes, heart
disease or stroke.
g) Trouble with memory or understanding: uncontrolled high blood pressure
may also affect your ability to think, remember and learn. Trouble with
memory or understanding concepts is more common in people with high
blood pressure.

10. Prognosis
The prognosis for hypertension depends on:
a) How long youve got it
b) How severe it is
c) If you have other conditions (such as diabetes) that increase the
risk of complication.
Hypertension can lead to a poor prognosis even if you do not have symptoms.
When high blood pressure is treated adequately, the prognosis is much better. Both
lifestyle changes and medicines can control your blood pressure

III. CONCLUSION

Hypertension was defined as persistent blood pressure where systolic pressure


above 140 mmHg and a diastolic pressure above 90 mmHg.
For most adults, there's no identifiable cause of high blood pressure. This type
of high blood pressure, called essential hypertension. Some people have high blood
pressure caused by an underlying condition. This type of high blood pressure, called
secondary hypertension.
Clinical manifestasi usually the patient feels : Fatigueorcnfs,vpblmhdyatigreu,obnlhpdcistekra
Like symptoms, physical findings depend on the cause of hypertension, its
duration and severity, and the degree of effect on target organs.
Diagnosis can be estabilished by check medical history, physical examinatior
and investigation. The treatment for Hypertension there is non pharmacologic
treatment such us modified daily life and pharmacologic treatment.
Uncontrolled high blood pressure can lead to Heart attack or stroke,
Aneurysm, Heart failure, Weakened and narrowed blood vessels in your kidney,
Thickened, Metabolic syndrome, Trouble with memory or understanding.
Hypertension can lead to a poor prognosis even if you do not have symptoms. When
high blood pressure is treated adequately, the prognosis is much better.
Diagnose for this patient is hypertension secondary, because according to the
laboratory test he have total cholesterol above people are normal.

REFERENCE

1. Weber at al. Clinical Practice Guidelines for the Management of Hypertension in


the Community A Statement by the American Society of Hypertension and the
International Society of Hypertension
2. Health Care Guideline Hypertension Diagnosis and Treatment. Institute for
Clinical Systems Improvement. 2012
3. http://www.who.int/mediacentre