HYPERTENSION

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General Patient Information

• Sam Street• 62 years old; male• African – American• Lives alone• Retired

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Chief Complaint• Occasional mild headaches• Dizziness after taking morning medications• Dissatisfied with his low sodium diet

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History of Present Illness• Occasionally mild headaches and some dizziness

after taking morning medications.• Dissatisfied with being placed on a low sodium

diet by his former primary care physician.• Reports “usual” chronic cough and shortness of

breath, when walking moderate distances.

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Past Medical History• Hypertension for 15 years• Type I Diabetes Mellitus• COPD, Stage 2 (Moderate)• Benign Prostatic Hyperplasia• Chronic Kidney Disease• Allergic to PCN (rash)

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Family History• Father deceased: acute MI at age 71• Mother deceased: lung cancer at age 64• Mother had both HTN and DM

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Social and Personal History• Former smoker (3 years ago) (smoked 1 ppd x 28

years)• Moderate amount of alcohol intake• Has been non-adherent to his low sodium diet• Does not exercise regularly and is limited

functionally by his COPD

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Review of Systems• Patient states that overall he is doing well and just getting

over a cold• Patient noticed no major weight changes over past few years• Complains of occasional headaches, relieved by

acetaminophen• Denies blurred vision and chest pain• SOB is “usual” for him and albuterol helps• Denies experiencing hemoptysis / epistaxis• Denies nausea, vomiting, abdominal pain, cramping,

diarrhea, constipation, or blood in stool.• Denies urinary frequency but states he used to have

difficulty urinating until physician started him on doxazosin a few months ago.

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Problem List1. Occasional mild headaches and dizziness after

taking morning medications2. COPD (SOB and usual chronic cough)3. Non compliance on low sodium diet4. HTN5. Type I DM6. CKD7. BPH

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Subjective• Dizziness and Occasional headaches after

morning medication taken• Does not like and does not comply to his low

sodium diet• Describes SOB and chronic cough when walking

moderate distances

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Objective• WDWN, no acute distress, moderately overweight• Vital signs of Px• BP 168/92 mmHg• HR 76 bpm (regular)• RR 16 per min• T 37ºC• Wt 95 kg• Ht 6’2”

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• HEENT• TMs clear; mild sinus drainage; AV nicking noted; no

hemorrhages, exudates, or papilledema• Neck• Supple w/o masses or bruits, no thyroid enlargement or

lymphadenopathy• Lungs• Lung fields CTA bilaterally. Few basilar crackles, mild

expiratory wheezing• Heart• RRR; normal S1 and S2. No S3 or S4

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• Abd• Soft, NTND; no masses, bruits, or organomegaly.• Normal BS

• Genit/Rect• Enlarged prostate; benign

• Ext• No CCE

• Neuro• No gross motor-sensory present. CN II-XII intact. A & O x 3.

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AssessmentLab Results Normal Values

Na = 142 mEq/L 135 – 145 mEq/LK = 4.8 mEq/L 3.5 – 5.0 mEq/L

Cl = 101 mEq/L 97 – 107 mEq/LCO2 = 27 mEq/L 23 - 29 mEq/LBUN = 22 mg/dL 6 - 20mg/dLSCr = 1.6 mg/dL 0.7 – 1.3 mg/dL

Glucose = 136 mg/dL

Normal glucose level = < 100 mg/dL after not

eating for at least 8 hours

Less than 140 mg/dLTwo hours after eating

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Lab Results Normal ValuesCa = 9.7 mg/dL 8.5 – 10.2 mg/dL

Mg = 2.3 mEq/dL 1.5 – 2.5 mEq/dL

HbA1C = 6.2%4 – 5.6 % (w/o diabetes)

6.5% borderline (w/ diabetes)

Alb = 3.5 g/dL 3.5 – 5.5 g/dLHgb = 13 g/dL 13.5 – 17 g/dL

Hct = 40% 38.8 – 50 %WBC = 9.0 x 103/mm3 5.0 – 10.0 x 103/mm3Plts = 189 x 103/mm3 150 – 400 x 103/mm3

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• Fasting Lipid Panel

Lab Results Normal ValueTotal Chol = 169 mg/dL < 200 mg/dL

HDL = 40 mg/dL ≥ 60 mg/dLLDL = 99 mg/dL < 100 mg/dLTG = 151 mg/dL < 150 mg/dL

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• Spirometry (6 months ago)• FVC 2.38 L (54% pred)• FEV1 1.21 L (38% pred)• FEV1/FVC 51%

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Urinalysis Normal values are as follows:

YellowYellow

(light/pale to dark/deep amber)

Clear Clear or CloudySG = 1.007 1.005 – 1.025

pH = 5.5 4.5 – 8(+) protein ≤ 150 mg/d(-) glucose ≤ 130 mg/d(-) ketones None(-) bilirubin Negative

(-) blood ≤ 3 RBCs(-) nitrite Negative

RBC = 0 / hpf ≤ 2 RBC/hpfWBC = 1-2 / hpf ≤ 2 – 5 WBC/hpf

Neg bacteria None1-5 epithelial cells ≤ 15 – 20 epithelial

cells/hpf

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• ECG• Normal sinus rhythm

• ECHO• Mild LVH, Estimated EF 35%

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• Diagnosis• Hypertension, uncontrolled• Type I diabetes mellitus, controlled on current insulin

regimen• Moderate COPD, stable on current regimen• BPH, symptoms improved on doxazosin

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Current Medical TreatmentMEDICATION DOSE

Triamterene/HCTZ 37.5mg/25mg po Q AM

Insulin 70/30 24 units Q AM, 12 units Q PM

Doxazosin 2mg po Q AM

Albuterol INH 2 puffs Q 4-6 PRN shortness of breath

Tiotroprium DPI 18mcg 1 capsule INH daily

Salmeterol DPI 1 INH BID

Entex PSE 1 capsule Q 12 h PRN cough and cold symptoms

Acetaminophen 325mg po Q 6 h PRN headache

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1.B How would you classify this px’s HTN according to JNC 7 Guidelines• BP 168/92 mmHg (sitting; repeat 170/90)• Stage 2 HTN

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1.c. What are the px’s known cardiovascular risk factors, and what is the px’s Framingham risk score?• Cardiovascular Risk Factors:

• Hypertension• Cigarette smoking• Physical inactivity• Moderately obese• Diabetes Mellitus• Age: 62 years old• Family History of HTN • Dyslipidemia

• Framingham risk score─ Risk>30%

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Framingham Risk Score

RiskFactors = (ln(Age) * AgeFactor) + (ln(TotalChol) * TotalCholFactor) + (ln(HDLChol) * HDLCholFactor) + (ln(SysBP) * SysBPFactor) + Cig + DM - AvgRiskRisk = 100 * (1 - RiskPeriodFactore(RiskFactors))

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• For women: Age Factor = 2.32888; Total Chol Factor = 1.20904; HDL Chol Factor = -0.70833; Avg Risk = 26.1931 and Risk Period Factor = 0.95012; SBP Factor if treated = 2.82263; SBP Factor if not treated = 2.76157

• For men: Age Factor = 3.06117; Total Chol Factor = 1.12370; HDL Chol Factor = -0.93263; Avg Risk = 23.9802 and Risk Period Factor = 0.88936; SBP Factor if treated = 1.99881; SBP if not treated = 1.93303

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1.d. What evidence of target organ damage or clinical cardiovascular disease does this px have?• BP 168/92 mmHg• Weight 65 kg• AV nicking• BUN = 22 mg/dL• SCr = 1.6 mg/dL• HbA1C = 6.2%• Alb = 3.5 g/dL• Hgb = 13 g/dL• HDL = 40 mg/dL

• LDL = 99 mg/dL• TG = 151 mg/dL

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DESIRED OUTCOME2. List the goals of treatment for this px:a) Reduce cardiovascular disease morbidity and

mortalityb) Reduce renal morbidity and mortalityc) Treat to BP <130/90 mmHg in patients with

diabetes or chronic kidney disease

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Therapeutic Alternatives3.a. What lifestyle modifications should be encouraged for this patient to achieve and maintain adequate blood pressure reduction?

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3.b. What reasonable pharmacotherapeutic options are available for controlling this patient’s blood pressure, and what co-morbidities and individual patient considerations should be taking into account when selecting pharmacologic therapy for his HTN? How might Mr. Street’s HTN medications potentially affect his other medical problems?• Triamterene / HCTZ• To treat water retention or high blood pressure• Reduce the amount of water in the body by increasing the

flow of urine, which helps lower the blood pressure.• Doxazosin• Alpha blocker

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4.a. Outline specific lifestyle modifications for this patient?• Weight loss of as little as 10 lbs (4.5 kg)• Exercise• Stretching• Walking• Stationary Bike• Leg Extensions• Exercise Diaphragm (COPD)• Chair Dance• Breathe right for Better Results

• Low Sodium Diet• Instead for MSG, Salt and the like, replace it with other

seasonings (pepper, garlic, herbs and lemon are good choices.)

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• Diet rich in fruits, vegetables, and low-fat dairy products with reduced content of dietary cholesterol as well as saturated and total fat

• Dietary sodium should be reduced to no more than 100 mmol per day (2.4g)

• Alcohol intake should be limited to no more than 1 oz (30ml) per day or if possibly alcohol intake can be halted for certain period of time.

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4.b. Outline a specific and appropriate pharmacotherapeutic regimen for this patient’s uncontrolled hypertension, including drugs, doses, dosage form, and schedule.

Drugs Dose Dosage Form Schedule

Triamterene /HCTZ

37.5mg/25mg

Tablet (Oral) Once daily every morning

Doxazosin 2mg Tablet (Oral) Once daily every morning after an hour taking Triamterene/ HCTZ

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5. Based on your recommendations, what parameters should be monitored after initiating this regimen and throughout the treatment course? At what time intervals should these parameters be monitored?• Patient should return for follow-up and adjustment of

medications at monthly intervals or less until BP goal is reached.

• More frequent visits for stage 2 HTN or with complicating comorbid conditions

• Serum potassium and creatinine should be monitored 1 – 2 per year

• After BP at goal and stable, follow-up at 3-6 months intervals• Comorbidities, such as heart failure, associated diseases, such

as diabetes, and the need for laboratory tests influence the frequency of visits

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6. Based on your recommendations, provide appropriate education to this patient.• Assess patient’s understanding and acceptance of the diagnosis of

hypertension• Discuss patient’s concerns and clarify misunderstandings• Tell patient the BP reading and provide written copy• Come to agreement with the patient on goal BP• Ask patient to rate (1 to 10) his chance of staying on treatment• Inform patient about recommended treatment and provide specific

written information about the role of lifestyle including diet, physical activity, dietary supplements, and alcohol intake.

• Use standard brochures when available.• Elicit concerns and questions and provide opportunities for the patient

to state specific behaviors to carry out treatment recommendations• Emphasize:

• Need to continue treatment• Control does not mean cure• One cannot tell if BP is elevated by feeling or symptoms• BP must be measured

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References:• Mosby’s Diagnostic and Laboratory Test Reference

5th Edition• Wellis, B. and et. al. Pharmacotherapy Handbook

2nd Edition• Berkow, R. and et. al. The Merck Manual of

Medical Information • Goodman and Gilman’s The Pharmacological Basis

of Therapeutics 12th Edition