Student instructions 

| Hypertension counselling

 You are a junior doctor completing a rotation in general practice

 A 53-year-old has presented for advice after being diagnosed with hypertension
 Please counsel the patient about hypertension (What is it? How is it managed?)
 At the end of the station, the examiner may ask you some further questions
Key details
53-year-old
Location: general practice
Hypertension counselling

Brief history
 I had my blood pressure taken at work as part of an annual checkup. The doctor said
the reading was really high, like 160/99mmHg.
 After the high blood pressure reading, I had to wear a blood pressure monitor at
home.
 After I gave it back to the GP surgery, a receptionist called me and told me to make
this appointment
 No conditions indicating secondary hypertension ("I don't have any other medical
conditions.")
 No known drug allergies

Perceptions
 ICE
o Ideas: “I assume I just have high blood pressure, which I know is common."
o Concerns: “I'm worried that I got told to make an appointment; I didn't think
high blood pressure was that big a deal!"
o Expectations: “I'm hoping you'll tell me it's easily treatable.”
 Exploration of hypertension
 Doctor's question: "Have you heard of hypertension/high blood pressure?"
 You have heard of hypertension ("Yeah, quite a few of my friends have high blood
pressure. I know it's quite common.")
 Doctor's question: "What do you know about high blood pressure?"
 You don't know much about hypertension (“I'd never actually thought about what it
was exactly or why it needs treating... I'm not sure.”)

Invitation
 Doctor's question: "Before I explain everything, is there anything you wanted to
ask?"
 You’re extremely nervous about why you had to have an appointment (”I thought
high blood pressure was quite common as you get older, so I'm a bit nervous that I
had to make this appointment. Is this really serious?”) 
Knowledge
 What is hypertension?
o Doctor's explanation: "The medical term for high blood pressure is
hypertension. Blood pressure is a measure of the force the heart uses to
pump blood around the body. It's determined broadly by the resistance in
your blood vessels, called your arteries, as well as the amount of blood in
your body."
o "Narrowing of the arteries can increase the resistance, so the heart has to
work harder to pump blood."
o "Arteries can narrow from the formation of fatty plaques, which can block
and clog arteries."
o "Plaques can form for lots of reasons: high cholesterol, diabetes, poor diet,
smoking, alcohol, etc."
o If you are not told about this then ask ("What actually is high blood
pressure?")
 Risk factors for hypertension
o Doctor's explanation: "There are several risk factors that increase a person's
risk of developing high blood pressure."
o "Blood pressure generally increases with age."
o "Ethnicity can be a factor too, with Black African and Black Caribbean patients
being at a higher risk of developing high blood pressure."
o "Lifestyle factors are important too. Smoking, excess alcohol and salt intake,
obesity, and a sedentary lifestyle can all increase your risk of developing high
blood pressure."
o If you are not told about this then ask ("Are there any risk factors for high
blood pressure?")
 Management of hypertension
o Doctor's explanation: "We have lots of medications that help to lower blood
pressure, which we prescribe in a step-wise approach, and there are lots of
options."
o "The type of medication we prescribe depends on your age, your ethnicity,
and whether you have certain other medical conditions such as diabetes. This
is because certain medications are found to be more effective based on these
factors."
o "Lifestyle changes are an excellent way to control blood pressure as well,
including modifying the risk factors I mentioned earlier. Reducing smoking,
alcohol and salt consumption, losing weight, and increasing the amount of
exercise you do is an important and effective way to reduce blood pressure." 
o "In fact, some patients can reduce their blood pressure back to normal
through these things alone without the need for drugs, which always come
with side effects."
o If you are not told about this then ask ("Are there any medications to help
high blood pressure?")
Exploration
 Patient question: "Are there any complications of having high blood pressure?" ~ if
not addressed
o Doctor's response: "Persistently raised high blood pressure can damage some
important organs in your body, including the eyes, the heart, and the
kidneys."
o "High blood pressure increases your risk of developing coronary artery
disease, peripheral artery disease, heart arrhythmias, and heart failure."
o "It increases your risk of having strokes and heart attacks. It also increases
the risk of developing vascular dementia, which is where a series of small
strokes build up and lead to brain tissue loss over time."
o "High blood pressure damages the kidneys by sometimes causing chronic
kidney disease."
o "Your eyes are sensitive to high blood pressure and can develop something
called hypertensive retinopathy."
o "As a result of all these increased risks, we treat blood pressure as high as
yours to reduce the risk of these complications of high blood pressure. It is
important to mention these increased risks can be mitigated by careful blood
pressure control, which ideally takes place in the form of a combination of
blood pressure-lowering drugs and lifestyle changes."

Strategy and summary

 Doctor's question: "Could you just summarise back to me the key points I’ve
explained, just to make sure I’ve made sense."
 You understand everything but you are fixated that you'll definitely have a heart
attack (”High blood pressure is linked to narrower arteries and/or an increased
amount of blood, so the heart has to pump harder." - "High blood pressure can be
treated with lots of medications to lower blood pressure." - "I'm almost definitely
going to have a heart attack because of this high blood pressure, although there are
loads of other complications too like stroke and chronic kidney disease.”) 
If the doctor doesn’t correct you about your certainty of a heart attack, provide them with
another opportunity with a prompt (”Am I right in thinking that I'm almost guaranteed to
have a heart attack then?”)
Set up
 Washes hands and dons PPE if appropriate
 Introduces themselves to the patient including name and role
 Confirms the patient's name and date of birth
 Explains the purpose of the consultation ~ explain hypertension 
 Gains consent to proceed
 Demonstrates that they are aware of the key pieces of background information
required for the consultation ~ what is hypertension, treatment options, risk factors
Perceptions
 Explores the patient’s prior knowledge/perception of hypertension to allow tailoring
of the explanation at the appropriate level
 Explores concerns and expectations the patient may have
 Encourages the patient to ask questions and contribute throughout the consultation
Invitation
 Offers to provide more information about hypertension
 Asks if the patient has any specific questions
 Checks what areas of information the patient would like to hear about and clarifies if
there is anything the patient would not like to know
 Confirms the patient wants to hear the information now and if they want anyone
else in the room
Knowledge
 Explains what hypertension is
 Describes risk factors for hypertension
 Describes complications of hypertension
 Explains management options for hypertension
 Delivers information in appropriately sized chunks
 Pauses at appropriate intervals to check understanding
 Avoids unnecessary jargon and explains medical concepts in patient-friendly terms
 Takes a considered approach to the quantity/depth of information conveyed based
on the patient’s prior knowledge and preferences
 Corrects any misunderstanding as they are encountered in a patient-friendly manner
 Provides additional resources that the patient can access later including websites,
apps, support organisations and leaflets
Exploration & empathy
 Explores how the patient feels about the information that has been given
 Demonstrates empathy throughout the consultation
Strategy & summary
 Checks the patient’s understanding by asking them to briefly summarise the key
points of the consultation - clarifies any misunderstandings if needed
 Checks the patient feels like their questions/needs have been addressed
 Demonstrates shared decision making by negotiating a mutually acceptable plan
 Provides safety-netting advice

Additional question: What would the first-line management for this patient be if they were
of black African or African-Caribbean ethnicity?
Ans: Calcium channel blocker