Annexure 9 A MODULE: 07 HYPERTENSION

1. Learning Objectives
End of the training the participants are able to Define and classify hypertension Record B.P and categorize the patient according to Joint National Committee (JNC) VII classification Identify risk factors Understand the pathophysiology involved in the elevation of blood pressure. Understand the pharmacological and non pharmacological approaches to manage hypertension Identify potential drug – drug interactions in prescription containing antihypertensive drugs Give important counseling points for specific antihypertensive agent.

2. Introduction
Hypertension is a clinical condition where there is elevation of blood pressure and it is an important risk factor for cardiovascular and cerebrovascular complications. The pharmacological management and non-pharmacological approaches plays major role in controlling and in preventing the complications of hypertension. Patients with hypertension should be encouraged to adopt healthy lifestyle modifications to control and prevent the progression of disease. To achieve a healthy impact on patient’s quality of life, a suitable antihypertensive that is safe, effective and economic should be selected based on individual’s clinical status.

3. Definition
Hypertension is defined as a clinical condition where a persistent elevation of arterial blood pressure (more than 120/80 mmHg) is observed in more than two consecutive recordings.

4. Classification
According to JNC classification, based on the extent of elevation in blood pressure, hypertension is classified as, pre-hypertension, stage-1 hypertension and stage-2 hypertension. CLASSIFICATION OF BLOOD PRESSURE Normal Pre-hypertension Stage 1 hypertension Stage 2 hypertension SYSTOLIC BLOOD PRESSURE (mmHg) <120 120-139 140-159 ≥160 DIASTOLIC BLOOD PRESSURE (mmHg) <80 80-89 90-99 ≥100

5. Epidemiology
Epidemiological studies have shown that hypertension affected approximately one billion individuals worldwide and this number is projected to increase to 1.56 billion by 2025. Hypertension is a major public health problem in India and other developing
Development, Validation and implementation of Continuous Professional Development (CPD) Programs for Community Pharmacists Page 134

pheocroma cytoma and thyroid disorders Development. The Framingham Heart Study suggests that individuals who are normotensive at the age of 55 will have a 90% lifetime risk for developing hypertension. Primary hypertension/essential hypertension: In primary hypertension.Annexure 9 A countries. In India. no specific cause can be identified however. 57% of deaths occur due to stroke and 24% of deaths occur due to coronary heart disease secondary to hypertension. About 90-95% of hypertension cases belong to this type and usual onset of primary hypertension is at the age of 36 years. Secondary hypertension: In secondary hypertension. About 5-10% of hypertensive patients belong to secondary hypertension and the usual onset of disease is after 55 years. Validation and implementation of Continuous Professional Development (CPD) Programs for Community Pharmacists Page 135 . In the population aged ≥60 years. Renal artery stenosis  Endocrine disorders like Diabetes mellitus. The epidemiological studies from rural and urban populations of India had shown that hypertension is emerging as a major health problem in India and is more in urban (25%) than in rural (10%) population. Risk factors for development of primary hypertension: 2. 6. acromegaly. Etiology Based on etiological factors hypertension is classified into two types: Primary hypertension and Secondary hypertension 1. there are certain risk factors that may contribute for development of hypertension. Cushing’s syndrome. there is an identifiable underlying cause for the development of hypertension. The common causes of secondary hypertension are as follows:  Renal disease like Chronic renal failure. 60% of the individuals will have hypertension.

the renin angiotensin aldosterone system (which regulates systemic and renal blood flow). Pathophysiology Blood pressure is the mathematical product of cardiac output and total peripheral resistance. Blood pressure is influenced by various neural and humoral factors. Development. Increased cardiac output: Increased cardiac preload: Increased fluid volume from excess sodium intake or renal sodium retention (From reduced number of nephrons or decreased glomerular filtration). Sympathetic nervous system over activity. renal function and renal blood flow (which influence fluid and electrolyte balance). insulin) and the vascular endothelium (which regulates the release of nitric oxide. 2. erythropoietin. 7. Sympathetic nervous system over activity. several hormonal factors (adrenal cortical hormones. prostacyclin and endothelin).Annexure 9 A  Pregnancy  Drugs such as steroids. Hence. Blood Pressure = Cardiac Output × Total Peripheral Resistance Potential Pathogenesis mechanisms 1. Validation and implementation of Continuous Professional Development (CPD) Programs for Community Pharmacists Page 136 . estrogen. vasopressin. Sympathetic nervous system over activity. thyroid hormone. bradykinin. Endothelial derived factors. An increase in cardiac output results in a compensatory decrease in total peripheral resistance hence blood pressure is maintained normal. These include the adrenergic nervous system (which controls alpha and beta receptors). NSAIDs. Genetic alterations of cell membranes. Genetic alterations of cell membranes. Endothelial derived factors. increase either in cardiac output or in total peripheral resistance leads to hypertension. Hyperinsulinemia resulting from obesity or metabolic syndrome. Structural vascular hypertrophy: Excess stimulation of renin-angiotensin-aldosterone system. Venous constriction: Excess stimulation of renin-angiotensin-aldosterone system. Normally Blood pressure is regulated by compensatory mechanisms that respond to changes in cardiac demand. increased peripheral resistance: Functional vascular constriction: Excess stimulation of renin-angiotensin-aldosterone system.

Non-pharmacological methods: All patients with pre-hypertension and hypertension should adopt certain life style modifications. 8. Non-Pharmacological method 2. however some patients complains of Headache Confusion and deficit memory Sleepiness Difficulty in breathing Tingling and numbness of hands and feet. Heart failure o Cerebrovascular complications: Stroke o Renal system complications: Renal failure. There is a direct association between sodium and blood pressure. Clinical features 8. Signs: The only sign of hypertension is elevated blood pressure measured using sphygmomanometer. Management of hypertension Hypertension cannot be cured but can be managed by following two methods: 1. Development. This mechanism stimulates the conversion of angiotensinogen to angiotensin-I.1. This in turn inhibits intracellular sodium transport.Chronic kidney disease o Opthalmic complications: Retinopathy 10. Angiotensin-II also stimulates the production of aldosterone which in turn leads to the retention of sodium and water resulting in increase in blood pressure.2. Validation and implementation of Continuous Professional Development (CPD) Programs for Community Pharmacists Page 137 .1. Symptoms: Most patients are asymptomatic. Patients with a high dietary sodium intake have higher prevalence of hypertension than those with a low sodium intake may be due to increased circulating natriuretic hormone. myocardial infarction. A decrease in blood pressure or decreased renal blood flow. Nephropathy. causing increased vascular reactivity and increased blood pressure. or volume depletion or decreased sodium concentration enhances the secretion of renin from the juxtaglomerulor cells in the kidney. 9. 8.Annexure 9 A Kidneys play an important role in the regulation of arterial pressure through the renin angiotensin aldosterone system. These approaches not only help in achieving the goal blood pressure and also reduce the progression of hypertension and antihypertensive drug dose requirement. Angiotensin converting enzyme (ACE) converts angiotensin-I to angiotensinII which is a potent vasoconstrictor that acts directly on arteriolar smooth muscles. Complications of hypertension o Cardiovascular complications: Angina. Pharmacological method 10.

Development.9 Kg/m2) 5-20mmHg/10Kg weight loss Weight reduction Adopt DASH (Dietary Consuming a diet rich in Approach to Stop fruits.2.SYSTOLIC BLOODPRESSURE REDUCTION Maintaining normal body weight (body mass index 18.Annexure 9 A JNC VII has recommended following life style modifications. stroke. vegetables and Hypertension) eating plan low fat dairy products Dietary restriction sodium Restricting daily dietary sodium intake to less than or equal to 2. chronic kidney disease. Validation and implementation of Continuous Professional Development (CPD) Programs for Community Pharmacists Page 138 .g. heart failure. Pharmacological methods: Goals of the treatment:  To decrease the elevated blood pressure.5-24.4 gram sodium or 6 gram of sodium chloride 8-14 mmHg 2-8 mmHg Physical activity Moderate alcohol intake Regular aerobic physical activity like brisk walking at least 30 min/day. retinopathy.  To reduce hypertension associated morbidity and mortality that is related to target organ damage e. Limiting alcohol consumption to less than or equal to 30mL ethanol/day for men and 15mL ethanol for women 4-9 mmHg 2-4 mmHg 6. for most patients the target blood pressure should be less than 140/90 mmHg and for those with diabetes and chronic kidney disease it should be less than 130/80 mmHg. According to JNC 7 recommendations. which provide reductions in blood pressure: MODIFICATION RECOMMENDATION APPROX.

Various types of diuretics are as follows: Type/Drug Dosage range(mg/day) Daily frequency Thiazide diuretics Hydrochlorthiazide 12. Phenytoin.5 1 Loop diuretics Furosemide 20-80 2 Torsemide 5 1 Potassium sparing Amiloride+ hydrochlorthiazide 5-10/50-100 1 Triamterene 50-100 1 or 2 Aldosterone antagonist Spiranolactone 25-50 1 or 2 Drug interactions:  ACE inhibitors. Diuretics: Diuretics are the most commonly used first line drugs in the management of hypertension. The long-term blood pressure lowering effects are maintained because of sustained decrease in peripheral vascular resistance as a result of vasodilatation of smaller blood vessels.25-25 1 Indapamide 1.  Increased auditory toxicity was observed when diuretics were used with Aminoglycosides. NSAIDs.Annexure 9 A Various classes of anti hypertensive drugs are used to treat hypertension. Validation and implementation of Continuous Professional Development (CPD) Programs for Community Pharmacists Page 139 .25-2. Diuretics are the drug of choice in elderly. Development.5 1 Metalozone 2. An appropriate choice of drug is mainly based on patient condition and on other concomitant diseases. Classification of antihypertensive agents:          Diuretics Beta-blockers Angiotensin converting enzyme inhibitors (ACEIs) Angiotensin receptor blockers (ARBs) and Calcium channel blockers (CCBs) Alpha-blockers Central alpha2 agonists Peripheral adrenergic agonists and Vasodilators 1. and Theophylline decreases the effects of diuretics. Aspirin. Diuretics induce natriuresis (urinary excretion of sodium) that results in decreasing the plasma volume.  Diuretics increase the effect of Propranalol Counseling points:  Ask the patient not to take any diuretic late in the evening as this drugs cause frequent urination in the night and may disturb the sleep. Paracetamol.5-50 1 Chlorthalidone 6. The choice of the drug varies from patient to patient.

increased intraocular pressure and rectal bleeding 2. These are the drugs of choice in patients with myocardial infarction. hypotension.  Ask the patient to avoid prolonged exposure to sunlight and wear protective clothing. diarrhea. angioedema. impotency. reduce central release of adrenergic substances and decrease renin release from the kidney. vomiting. flushing.  Methimazole.5-10 50-200 Daily frequency 1 1 2 40-120 160-480 10-40 1 2 1 200-800 2. restlessness. frequent urination and hearing impairment. lower the heart rate. metabolic alkalosis. angina and heart failure. hypokalemia. drowsiness. hyperglycemia. hypochloremia. hypocalcemia. palpitation. photosensitivity.  Ask the patient to avoid alcohol. photosensitivity. sensitive to sunlight. cramping. Development. Beta-blockers: Beta-blockers act by blocking beta adrenergic receptors and decrease cardiac contractility and output. constipation. Different types of beta blockers are as follows: Type/Drug Cardioselective Atenolol Bisoprolol Metoprolol Non-selective Nadolol Propranalol Timolol Intrinsic sympathomimetic activity Acebutalol Carteolol Pindolol Mixed alpha and beta blockers Carvedilol Labetalo Dosage Range(mg/day) 25-100 2. Validation and implementation of Continuous Professional Development (CPD) Programs for Community Pharmacists Page 140 .5-50 200-800 2 1 2 2 2 Drug interactions:  Aspirin and NSAIDs decreases the effects of beta-blockers. dizziness. as alcohol consumption can add to drowsiness caused by the drug. sunglasses or sunscreen as these drugs make skin.5-10 10-60 12. nausea. epigastric distress. anorexia. Adverse effects: Common: Orthostatic hypotension. weakness. verapamil and Frusemide increases the effects of beta-blockers. alopecia. All these contribute to their antihypertensive effect.Annexure 9 A  Ask the patient not to drive automobiles or operate machinery as these drugs can cause drowsiness. hyperuricemia. Rare: Anaphylaxis. hypomegnesemia. vertigo. light headedness. anorexia.

diarrhea. psychosis and impotency. which results in decreased levels of angiotensin II which is a potent vasoconstrictor. Angiotensin converting enzyme inhibitors (ACEIs): ACEIs inhibits the conversion of angiotensin I to angiotensin II by competitively inhibiting angiotensin converting enzyme. as alcohol consumption can add to drowsiness caused by the drug. reduced exercise tolerance.Annexure 9 A Counseling points:  Advice the patient not to stop beta-blockers without consulting their physician as sudden stoppage of these drugs may cause chest pain. advice the patient who is using contact lens to talk with their doctor for changing over to spectacle  Advice the patient regarding possibilities of nocturnal dreams and impotence due to these drugs. wheezing. headache. cold extremities. increased liver enzymes. Adverse effects: Common: Hypotension. Adverse effects: Common: Hypotension. nightmares.5-15 5-40 10-40 10-40 4-16 2. photosensitivity. Development. impotence. angioedema. Validation and implementation of Continuous Professional Development (CPD) Programs for Community Pharmacists Page 141 . constipation. to inform her doctor if she is pregnant or if become pregnant while taking these drugs as these drugs can harm the fetus. bradycardia. depression. ototoxicity. bronchospasm. tachycardia and fatigue Rare: Gynaecomastia.  Ask the patient to avoid alcohol. Counseling points:  Advice female patients. rashes. photosensitivity. constipation. nausea. tiredness. diabetic nephropathy. blurred vision. dizziness.5-10 1-4 Daily frequency 1 or 2 2or 3 1 or 2 1 1 1 1 or 2 1 Drug interactions:  Aspirin decreases the effects of ACE inhibitors. vomiting. confusion and bronchospasm. increased urea and serum creatinine. taste disturbance. 3. cough.  Ask the patient not to drive automobiles or operate machinery as these drugs can cause drowsiness. anorexia. dizziness. Drug Benazepril Captopril Enalapril Lisinopril Fosinopril Perindopril Ramipril Trandolapril Dosage range (mg/day) 10-40 12. These are the drugs of choice in patients with heart failure. cold peripheries. ataxia. psychosis.  ACE inhibitors decrease the effects of loop diuretics.  As this drugs can cause dryness of eyes. heart attack or irregular heartbeats. Rare: Alopecia elevated liver enzymes. Steven Johnson Syndrome and toxic epidermal necrolysis. chest pain. drowsiness.

Adverse effects: Common: Edema. Counseling points:  Advice female patients. Angiotensin receptor blockers (ARBs): ARBs are angiotensin receptor antagonists.  Effect of verapamil/Nifedipine decreases when used along with phenytoin or Rifampicin Development. headache.  Rifampicin decreases the effects of ARBs. fever. anxiety and depression Rare: Anaphylactoid reaction. These are the drug of choice in elderly with isolated systolic hypertension. 5. sinusitis. nasal congestion. There are two types of CCBs namely. Type/Drug Dosage (mg/day) range Daily frequency Dihydropyridines Amlodipine 2.5-10 1 Felodipine 5-20 1 Isradipine 5-10 2 Nicardipine 60-120 2 Nifedipine 30-90 1 Non-dihydropyridines Diltiazem 180-320 2 Veerapamil 100-400 1 Drug interaction:  CCBs produce additive effects when used with beta-blockers. to inform her doctor if she is pregnant or if become pregnant while taking these drugs as these drugs can harm the fetus.Annexure 9 A 4. Drug Losartan Candesartan Irbesartan Telmisartan Valsartan Dosage range Daily frequency (mg/day) 50-100 1 or 2 8-32 1 or 2 150-300 1 20-80 1 80-320 1 Drug interactions:  Fluconazole increases the effects of ARBs. weakness. orthostatic hypotension. dihydropyridines and non-dihydropyridines. Validation and implementation of Continuous Professional Development (CPD) Programs for Community Pharmacists Page 142 . angioedema. weight gain. flu like syndrome. abdominal pain.Calcium channel blockers (CCBs): CCBs relax vascular smooth muscles by inhibiting calcium ions from entering the slow channels or voltage sensitive areas of vascular smooth muscles and myocardium during depolarization. first dose hypotension. peripheral neuropathy and vertigo. palpitations. alopecia. elevated liver enzymes. patients with myocardial infarction and angina. dyspepsia. which acts by competitively blocking the angiotensin receptors resulting in decreased vasoconstriction. psychosis. These are the drugs of choice in patients who are intolerant to ACEIs.

edema. tinnitus. reddened sclera and nasal congestion Rare: Allergic reactions. edema. nervousness.  Advice the patient to get out of the bed slowly by resting their feet on the floor for few minutes before standing up. Methyldopa is the drug of choice in Development. Steven Johnson Syndrome. elevated liver enzymes. constipation. dry mouth and blurred vision. which reduces sympathetic outflow from the vasomotor centre and increases vagal tone.Alpha blockers: These are selective alpha 1 blockers that inhibits catecholamine uptake in smooth muscle cells of the peripheral vasculature resulting in vasodilatation. 7.  Inform to patient alpha blockers may cause dizziness. weight loss. tinnitus. light-headedness. ask them to take alpha blockers just before going to bed. headache. male sexual dysfunction. chest pain. Peripheral stimulation of presynaptic alpha 2 receptor leads to reduction in sympathetic tone hence there is a decrease in heart rate. postural hypotension. alopecia. diarrhea. drowsiness. weakness. Adverse effects: Common: Dizziness. nausea. increased urinary frequency. cardiac output. total peripheral resistance and plasma renin activity. postural hypotension. skin discoloration. flushing. dizziness.  Ask the patient to sit or lie down if they experience dizziness or lightheadedness. vomiting.myalgia. hallucinations. constipation. 6. lightheadedness and fainting when they get up too quickly from lying position. swollen joints. muscle cramps. tremors and photosensitivity Rare: Alopecia. Drug Dosage range (mg/day) Daily frequency Prazosin 2-20 2 or 3 Terazosin 1-20 1 or 2 Doxazosin 1-8 1 Drug interactions:  Alpha blockers produce additional hypotensive effects when used along with other antihypertensives  NSAIDs decreases the effects of alpha blockers. palpitation. Counseling points:  If the patient is taking alpha blockers for the first time. These are the drugs of choice in patients with dyslipidaemia. pruritus.Annexure 9 A Counseling points:  Advice the patient to avoid alcohol as CCBs may increase the effects of alcohol Adverse effects: Common: Swollen gums. palpitations. Validation and implementation of Continuous Professional Development (CPD) Programs for Community Pharmacists Page 143 . depression. leucopenia. migraine. dyspnoea. rash.Centrally acting alpha 2 agonists: These agents lower blood pressure by stimulating alpha 2 adrenergic receptor in the brain. impotence.

1000 2 Drug interactions:  Clonidine masks the hypoglycemic symptoms caused due to oral hypoglycemic agents or insulin  Alpha 2 agonists produce additive CNS effects when used along with barbiturates and other CNS depressants  Beta-blockers potentiate bradycardia when used along with Clonidine  Tricyclic antidepressants decrease the effects of Clonidine. sedation. headache. less than the usual amount of norepinephrine is released into the synapse. myalgia. Development. weight gain. black tongue.05-0.  Advice the patient to avoid alcohol as alcohol may worsen the side effects of reserpine.5 – 0. This results in reduced sympathetic tone. vertigo. lightheadedness. blurred vision. nausea.  Advice the patient to avoid alcohol as alcohol may worsen the side effects of these drugs Adverse effects: Common: Drowsiness. bradycardia.Peripheral adrenergic agonists: These agents deplete norepinephrine from sympathetic nerve endings and block the transport of norepinephrine into its storage granules. nervousness. Counseling points:  Advice the patient not to stop taking alpha 2 agonists suddenly as it can cause abrupt rise in blood pressure. headache and confusion  Ask the patient not to drive automobiles or operate machinery as alpha 2 agonists can cause drowsiness. diarrhea. dry mouth.  Ask the patient not to drive automobiles or operate machinery as reserpine can cause drowsiness. weakness.Annexure 9 A pregnancy and patients with resistance hypertension unresponsive to first line therapy. decreased libido. Gynaecomastia and amenorrhea. decreasing peripheral vascular resistance and blood pressure. Counseling points:  Advice the patient not to stop taking reserpine abruptly. edema. 8. Drug Dosage range Daily frequency (mg/day) Clonidine 0. dizziness. Drug Dosage range Daily frequency (mg/day) Reserpine 0. Rare: Hemolytic anemia. Validation and implementation of Continuous Professional Development (CPD) Programs for Community Pharmacists Page 144 . When the nerve is stimulated. fever. increased blood urea nitrogen.8 2 Methyldopa 250 . breast enlargement.25 1 Drug interactions:  Reserpine produces additive hypotensive effects when used along with betablockers and diuretics  Tricyclic antidepressants decreases the hypotensive effects of reserpine. vomiting.

Rare: Breast tenderness. anorexia and edema. abdominal cramps. hypertrichosis (elongation.Direct arterial vasodilators: These agents cause direct arteriolar smooth muscle relaxation. Rare: Dysuria. weight gain. CCBs Beta-blockers ACE inhibitors Alternatives ARBs Drugs to avoided be -Diuretics. galactorrhea and gynaecomastia 9. gynaecomastia. anxiety.Betablockers. -Calcium channel blockers Methyldopa Beta-blocker (Labetalol) CCBs ACE inhibitors and ARBs (in women of child bearing age) ACE inhibitors and ARBs Pregnancy (Preeclampsia) Development.  Inform patient that vasodilators may cause chest pain and advice patient to see their doctor immediately if chest pain occurs or worsens.  Ask the patient not to drive automobiles or operate machinery as vasodilators can cause drowsiness. diarrhea. thickening and increased pigmentation of fine body hair).Annexure 9 A Adverse effects: Common: Fatigue. Management of hypertension in special populations: Special population Elderly With Hypertension alone Hypertension with angina Hypertension with diabetes or heart failure Children and adolescent Drug of choice Diuretics. depression. elevated liver enzymes. nausea. lacrimation. tachycardia. dizziness. These are the drugs of choice in patients with resistance hypertension unresponsive to first line therapy. bradycardia. headache. Counseling points:  Advice the patient to avoid alcohol as alcohol may worsen the side effects of these drugs. vomiting. Adverse effects: Common: Headache. edema. drowsiness. blurred vision. Validation and implementation of Continuous Professional Development (CPD) Programs for Community Pharmacists Page 145 . Drug Dosage range Daily frequency (mg/day) Hydralazine 20-100 2 to 4 Minoxidil 10-40 1 or 2 Drug interactions:  Hydralazine increases the serum levels of beta-blockers  NSAIDs decreases the effects hydralazine  Minoxidil produces additive hypotensive effects when used with other antihypertensive agents. ACE inhibitors.

weight reduction if overweight.4 gram/day). deficit memory etc. and storage condition for all the drugs. Important counseling points: All hypertensive patients must be counseled about the disease.  Patient must be encouraged to visit his/her physician regularly that helps him/her to have a better understanding about their clinical outcome.  Patient should be made aware of all the possible adverse reactions to the drugs and should be encouraged to report such reactions if at all they experience the same. how to take (before food or after food). Counseling about the disease:  Patient must be counseled about the signs and symptoms of the disease such as headache. Counseling about the drugs:  Patient must be made aware of treatment that they are receiving for controlling hypertension. restricting alcohol consumption. Validation and implementation of Continuous Professional Development (CPD) Programs for Community Pharmacists Page 146 .  Patient must be told that hypertension is not curable disorder. however patients must be reassured that the disease can be well controlled by taking medications regularly and also by adopting certain life style modifications.  Patient must be told that they have to take their medication regularly throughout their life in order to control the blood pressure. purpose. dose. medication and life style modifications in order to improve their clinical condition. if alcoholic (<30mL/day for men and < 15mL/day for women). Development. physical activity like brisk walking. Counseling about the life style modification:  Patient must be encouraged to adopt certain life style modifications like salt restricted diet(< 2. low fat diet.  In cases if they forgot to take their medication patient must be told that they can take medication as soon as they remembers it but if the time is very close to next dose they should not double the dose in such situations they must avoid previous dose and simply take the drug during next dose. sleepiness.  Patient must be told about the name. confusion.  The attempts should be made that the patient must understand and believe that hypertension is a serious condition that needs treatment. when to take (morning or afternoon or at night).  Patient must be made aware of consequences of untreated hypertension.  Patients must be encouraged to take the medications regularly without fail at same time every day.Annexure 9 A Hypertension asthma or COPD Hypertension dyslipidaemias with -with Alpha-blockers ACE inhibitors CCBs Thiazide diuretics Beta-blockers -Non selective Beta-blockers 11. modifications in their treatment according to clinical outcome.

His social history reveals that he is a regular smoker and smokes about 1 packet of cigar a day for the last ten years. Mr. Place the bladder over the brachial artery 4. Use appropriate sized cuff 2. complaining of severe headache and consulted a general practitioner. Case Studies Case-1 Mr. Upon enquiry. He also drinks about 90 ml of alcohol two to three times a week. VK’s case? e) What counseling points are necessary for Mr. Mr. Palpate the radial pulse while cuff is inflated 5.Annexure 9 A 12. KS mentioned that. a) What do Mr. Ensure tight wrapping of cuff around the arm 3. VK symptoms represent? b) What objective and subjective parameters are necessary to confirm the diagnosis? c) What risk factors led him to the present situation? d) What is the appropriate management in Mr. in recent times he has experienced this type headache and sometimes he felt that he was going in to a state of confusion.P? B. KS a 40 year old circle inspector. His social history says that he is a known smoker and smokes one pack of cigarettes every day.P Recording Steps 1. VK’s B. Deflate the cuff at a rate of 2 mmHg/sec while listening to Korot Koff sounds 8. He expresses a feeling that he might have developed hypertension and seek for BP check up. Activity for the participants Mr. what steps would you follow to record B. Inflate the cuff rapidly to 20 -30 mmHg above estimated blood pressure 7. complaining severe headache visited your pharmacy for a prescription. Twice or thrice a week he drinks 180 ml of rum. Observe the manometer simultaneously to record blood pressure. VK a 45-year-old marketing executive weighing 85 Kgs and whose height is 5’10’’. VK regarding the medications. On examination. diet and other life style modifications? Development.P was 150/95 mmHg. 13. Position the stethoscope over the brachial artery 6. Validation and implementation of Continuous Professional Development (CPD) Programs for Community Pharmacists Page 147 .

His case record suggests that his BP was 155/95 mmHg. SR a 48 year old marketing executive received a prescription for his elevated BP (151/92 mmHg). A 35 year old man weighing 90 Kgs.SR? Development.Annexure 9 A Case – 2 Mr. On enquiry. Amodep AT Tab. Atorva 10mg 1 OD morning after breakfast 1 OD at bed time. Tab. Validation and implementation of Continuous Professional Development (CPD) Programs for Community Pharmacists Page 148 . 1. What are the probable risk factors for Mr. visited the pharmacy with a prescription containing Metoprolol 25 mg OD. SR’s elevated BP? 2. JK. His doctor has prescribed him Rx. JK? Case -3 Mr. What dietary and life style modifications are required for Mr. JK’s elevated blood pressure? b) What is the medicine prescribed to Mr. JK may experience if his blood pressure is not controlled? d) What are the counseling points for Mr. What counseling points should be provided to Mr.SR regarding his medication? 3. His parents were also hypertensive and his father died with acute MI six months ago. JK and how does this drug benefits him? c) What consequences Mr. he told that he is real estate broker and he smokes more than 15 cigarettes a day and drinks 180 ml of whiskey every day. His lab data reveals that triglycerides were elevated. His social history reveals that every day he smokes 2 packs of cigarettes and two drinks of whisky. a) What are the causes of Mr.

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