CASE OF 40 YEARS MALE WITH HYPERTENSION

• STUDENT NAME: MOHAMMED IBRAHIM ALMUNDARIJ

• ID: 381121126
• ROTATION: INTERNAL MEDICINE
• PRACTICE SITE: BUKAYRIAH GENERAL HOSPITAL
• SUPERVISOR NAME: DR.RAMI
:Objectives of the presentation

 Providing brief introduction about Hypertension.

 Identifying the main patient information.
 Comparing the guideline used in hospital for the management of Hypertension to the US guideline.
 Identifying the drug related problems (DRPs) and providing suggestions for better management.
 Monitoring of patient outcomes.
 Providing patient education.
 Providing conclusions.

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 INTRODUCTION

 Hypertension :progressive cardiovascular syndrome caused by a variety of complex and interconnected etiologies
which cause persistently elevated arterial blood pressure with a systolic blood pressure greater than 130 mmHg or a
diastolic blood pressure greater than 80 mmHg.5
 prevalence : A study with 17,230 participants was conducted. Hypertension was found in 26.1% of people. Males had
a 28.6% prevalence of hypertension, while females had a significantly lower prevalence of 23.9%. The prevalence of
hypertension in the urban population was significantly higher (27.9%) than in the rural population (22.4%).6
 The majority of cases of hypertension are idiopathicknown as essential hypertension. Also There are several
mechanisms described for the development of hypertension, including increased salt absorption resulting in volume
expansion, an impaired response of the renin-angiotensin-aldosterone system (RAAS), and increased sympathetic
nervous system activation which may lead to early symptoms of hypertension.10

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 INTRODUCTION

RISK FACTOR11

 Modifiable risk factors :  Non-Modifiable risk factors :

 Obese or overweight   Family history

 Excessive salt (sodium) in the diet.  Age over 65 years

 Being physically inactive.  Co-existing diseases such as diabetes

 Insufficient potassium in the diet  Gender

 smoking

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 Patient Information
Demographic Description
Patient Name Ahmed alsadrani

Gender male

Age 40
Nationality saudi
19/09/22
Date of Admission
21/09/22
Date of Discharge
Weight 50kg
Height 150cm
CHIEF COMPLAINT
HEADACHE ASSOCITED WITH BLURRED VISION AND EXCESSIVE SWEATING. 5
 PATIENT INFORMATION (CONT…)

 Past surgical history

 NO SURGICAL HISTORY

 Family history
 NO FAMILY HISTORY

 Allergies
 History of allergies: Yes [ ] if yes, identify…………………... No known allergies [ x ]
 Social history
 Smoking Yes [* ] No [ ] Don’t know [ ]
 Alcohol Yes [ ] No [ * ] Don’t know [ ]
 Drug Abuse Yes [ ] No [ * ] Don’t know [ ]

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PATIENT INFORMATION (CONT…)

History of present illness

 

HE HAD HISTORY OF HIGH BLOOD PRESSURE READING BEFORE 3 WEEKS

PAST MEDICAL/MEDICATIONS HISTORY0

Medication Indication
   
   
   

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PATIENT INFORMATION (CONT…)

I. Physical Examination
  Vital signs
System
Chest normal  Temperature °c
36.5

CVS
NO ABNORMAL Blood pressure 170/110mmHg
DETECTION
Abdomen soft  Pulse 69beat/min
CNS normal  Respiratory Rate 20b/min
Lung Bronchial asthma  Oxygen Saturation 98%
Limb No edema 
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PATIENT INFORMATION (CURRENT MEDICATIONS)

Name/Dose/Route Frequency of Use Indication Start Date Stop Date

 Telmisartan 40mg tab BID  hypertension  21/9  21/10

21/10
 Atorvastatin 20 mg tab OD  hyperlipidemia  21/9 

 Hyoscine-n-butylbromide 10mg tab TID  -  21/9  28/9

21/10
 Esomeorazole 20mg tab OD  -  21/9 
21/10
 OMEGA1000mg tab OD  hyperlipidemia  21/9 

       
       
       
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PATIENT INFORMATION (LAB DATA)

Hematology  Normal range 1 2 3 4 5 6 7

WBC 4 – 11 mcg/dl  10.7             
RBC 4.04-6.13 mu/10^9rbc   5.5            
HGB 13 – 17.4 g/dl   15.8            
HCT 33-52%   50            
MCV 78-96 FL   91            
MCH  27 – 32 Pg  28            
MCHC 29-37 g/dL   31            
Platelets 150-450 mcg/dl   315            
Neutrophils                
Lymphocyte                
Monocyte                
Eosinophil                
Basophil                
Reticulocytes
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PATIENT INFORMATION (LAB DATA)

 NORMAL LAB RESULT

 Liver function

Test Normal range 1

AST 0-40 U/L 23 U/L
ALT 0-41U/L 31 U/L
ALP 35-130 U/L 56 U/L
 Normal Liver function

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PATIENT INFORMATION (LAB DATA)

Renal Profile & Electrolytes :

Test Normal Range 1

Na+ 136-145 mmol/L 137

K+ 3.5-5.1 mmol/L 4.04

Serum Cr 44-106 umol/L 113 umol/L

 The lab results revealed a slight increase in cr.

 Lipid profile:
Test Normal Range 1
Cholesterol mg/dl 50-200 236mg/dl
LDL mg/dl 130< 151mg/dl
HDL mg/dl 40-60 54.7mg/dl
Triglycerides mg/dl 50-200 318.1mg/
dl

• lab result is abnormal high cholesterol and LDL and triglycerides indicate dyslipidemia
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PATIENT INFORMATION (DAILY FOLLOW UP)

Subjective / Objective Assessment / Plan

Day 1
S HEADACHE ASSOCITED WITH  A Hypertension newly 
BLURRED VISION AND EXCESSIVE
.SWEATING

O BP:170/110mmHg
PR:70 b/min
P Telmisartan 40mg 2 tab once a day
Omeprazole
O2: 98 % Hyoscine-n-butylbromide 10mg TID
TEMP:36.6C

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PATIENT INFORMATION (DAILY FOLLOW UP)

Subjective / Objective Assessment / Plan

Day 2
S No complain  A Hypertension newly 

O BP:139/90mmHg
PR:85 BMP P Telmisartan 40mg 2 tab once a day
Omeprazole
% O2: 95 Hyoscine-n-butylbromide 10mg TID
TEMP:36.6C
RR: 20 b/min

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PATIENT INFORMATION (DAILY FOLLOW UP)

Subjective / Objective Assessment / Plan

Day 3
S No complain  A Hypertension 

O BP:135/85mmHg
PR:69 BMP P : DISCHARGE
Telmisartan 40mg
% O2: 98 Atorvastatin 20 mg
TEMP:36.6C Hyoscine-n-butylbromide 10mg
RR: 20 b/min Esomeorazole 20mg
OMEGA1000mg

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 Discussion
Comparison between treatment of the patient’s main problem in the hospital and guideline for treatment of
the same problems

Current (Hospital) Treatment Guideline Management (US Guideline)

   
• Telmisartan 40mg BID International Society of Hypertension global
• Atorvastatin 20 mg OD hypertension
• Hyoscine-n-butylbromide 10mg TID practice guidelines – lifestyle modification 2020.
• Esomeorazole 20mg OD In patient with grade 2 hypertension (≥ 160/100):
• OMEGA1000mg OD - Start drug treatment immediately
- Start lifestyle intervention.
  Step 1 ‫ ـــــ‬Low dose of ACEI/ARB* and DHP-CCB
Step 2 ‫ ـــــ‬Increase to full dose
  Step 3 ‫ ـــــ‬Add thiazide/thiazide like diuretic
  Step 4 ‫ ـــــ‬Add spironolactone, if not tolerated or
contraindicated, amiloride, doxazosin,eplerenone,clonidine
  or beta-blocker.
 
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 Discussion
Comparison between treatment of the patient’s main problem in the hospital and guideline for treatment of
the same problems

Current (Hospital) Treatment Guideline Management (US Guideline)

   Lifestyle intervention:
• Regular exercise
  • Salt reduction
• Healthy diet and drinks
  • Lower stress
  • Reduce exposure to air pollution
Goal: BP less than 130/80 mmHg
 
  Hypertensive patient with lipid disorder:
  - According to guideline, 10-year CVD risk is estimated and
the patient was 5%-7.5% so moderate intensity statin
 
therapy should be given .
  - Statin: Atorvastatin 20 mg daily
- Goal: LDL-C less than 100mg/dl
- Start healthy lifestyle 17
 DRUG RELATED PROBLEMS (DRPS)

# DRP Specific Recommendation to solve the

DRP
1 Brief explanation of the DRP: wrong choice of • I recommend that the patient be given a dual drug
drug (Telmisartan 40mg bid ) of Telmisartan40mg / amlodipine5mg once daily
Cause of DRP: wrong choice because it has a better effect than Telmisartan alone.
Unger, Thomas, et al. "2020 International Society of Hypertension global hypertension practice
guidelines." Hypertension 75.6 (2020): 1334-1357.
Kim, Bong-Joon, et al. "Effect of a fixed-dose combination of Telmisartan/S-amlodipine on circadian blood
pressure compared with Telmisartan monotherapy: TENUVA-BP study." Clinical hypertension 28.1 (2022):
1-10.

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 DRUG RELATED PROBLEMS (DRPS)

# DRP Specific Recommendation to solve the

DRP

2 Brief explanation of the DRP: Unnecessary drug • I Recommend to Stop Hyoscine-n-butylbromide.

therapy (Hyoscine-n-butylbromide )
Cause of DRP: Medication without indication
Schneider R, Salerno J, Brook R. International Society of Hypertension
global hypertension practice guidelines – lifestyle modification. Journal of
Hypertension. 2020;38(11):2340-2341.

3 Brief explanation of the DRP: Unnecessary drug • I Recommend to Stop Esomeprazole.

therapy (Esomeprazole)
Cause of DRP: Medication without indication.
Schneider R, Salerno J, Brook R. International Society of Hypertension
global hypertension practice guidelines – lifestyle modification. Journal of
Hypertension. 2020;38(11):2340-2341.

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 *Monitoring of Patient Outcome

*Disease Therapeutic Goal *Monitoring Parameters Desired Date

Endpoints
  lower high blood Signs & symptoms:nosebleeds, BP less than 130/80 21/10 
Hypertension pressure and protect irregular heart rhythms, headaches mmHg 
Telmisartan40mg / important organs, like
amlodipine5mg
the brain, heart, and Most common side effects: Avoid side effect   
kidneys from damage  lightheadedness , Swelling
hands/ankles
Drug interactions:    

NONE
Labs:    
blood tests blood pressure,  potassium
level

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 PATIENT EDUCATION

Pharmacological :
 Telmisartan40mg / amlodipine5mg -It can be taken in the morning or at bedtime to effectively lower
blood pressure. When medications are administered at bedtime, there is a trend toward better BP
lowering and less BP variability. With or without food.
 Atorvastatin 20 mg-should be taken at bedtime .

Non‐pharmacological :
 Changes in lifestyle, such as dietary patterns, special diets with low sodium, saturated fat, and high
calcium, magnesium, and potassium, also increase physical activity, avoid stress, and smoking cessation.

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 Conclusion

 A 40-year-old patient complains of headaches, blurred vision, and increased sweating; he is diagnosed with
hypertension and treated in the Department of Internal Medicine within three days; he is then discharged
home. I found 3 drugs related problems (DRPs) in this case and made my recommendation to solve them
according to the guideline to improve patient’s quality of life.

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 References

1. Unger, Thomas, et al. "2020 International Society of Hypertension global hypertension practice guidelines." Hypertension 75.6 (2020): 1334-1357. 

2. Moen MD. Telmisartan/amlodipine: single-pill combination in hypertension. Am J Cardiovasc Drugs. 2010;10(6):401-12. doi: 10.2165/11204880-000000000-00000. PMID: 21090832.

3. Murdoch, David, and Rennie C. Heel. "Amlodipine." Drugs 41.3 (1991): 478-505.

4. Kim, Bong-Joon, et al. "Effect of a fixed-dose combination of Telmisartan/S-amlodipine on circadian blood pressure compared with Telmisartan monotherapy: TENUVA-BP study." Clinical hypertension 28.1
(2022): 1-10. 

5. Giles, T. D., Materson, B. J., Cohn, J. N., & Kostis, J. B. (2009). Definition and classification of hypertension: an update. The journal of clinical hypertension, 11(11), 611-614.

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7. Hall, John E., et al. "PATHOPHYSIOLOGY OF HYPERTENSION." Hurst's The Heart, 14e Eds. Valentin Fuster, et al. McGraw Hill, 2017, 

8. Kannel, William B. "Risk factors in hypertension." Journal of cardiovascular pharmacology 13 (1989): S4-10.

9. Billecke, Scott S., and Pamela A. Marcovitz. "Long-term safety and efficacy of telmisartan/amlodipine single pill combination in the treatment of hypertension." Vascular Health and Risk Management 9
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10. Carretero, Oscar A., and Suzanne Oparil. "Essential hypertension: part I: definition and etiology." Circulation 101.3 (2000): 329-335. 

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 References

11. Ewald, D. Rose, and Lauren A. Haldeman. "Risk factors in adolescent hypertension." Global pediatric health 3 (2016): 2333794X15625159.

12. Ibekwe, R. U. "Modifiable risk factors of hypertension and socio demographic profile in Oghara, Delta state; prevalence and correlates." Annals of medical and health sciences research 5.1 (2015): 71-77.

13. Peng GC, Wang YF, Xiao Y, Chen JF, Yang Y, Ye YL, Sai SQ, Huang JX. [Blood pressure lowering efficacy of telmisartan and amlodipine taking on the morning or at bedtime: ABPM results]. Zhonghua Xin Xue Guan Bing Za
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THANK YOU

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