How do the Curriculum Themes Contribute?
Therapeutics
Drug and non-drug treatment is the topic of one of the fourth year
therapeutic tutorials. Fifty patient management cases on therapeutics are
now available on the Ninewells Server.
Investigative Procedures
Biochemical medicine
All patients with raised blood pressure require their urea and electrolytes
checked for renal impairment; plasma glucose; and cholesterol estimation.
These simple tests can help stratify a risk profile. Nowadays we are
increasingly aware that between 5 and 15% of unselected hypertensives
have Conn’s Syndrome. Renin and aldosterone and catecholamines
measurements are also done in all new referrals.
Nurse Led Assessment Clinic: At present this is held in wards 5/6 but it
may shortly move to the clinical investigation unit. Here you will see
patients being fitted with ambulatory blood pressure monitors as well as
having a number of other measurements taken.
Radiology: Young patients with raised blood pressure and evidence of renal
impairment require renal ultrasound. Obstruction, scarring and reduced
renal size are indicative of pyelonephritis and renal artery stenosis. Renal
angiography is carried out on selected patients to confirm renal artery
stenosis and about 30 renal angiograms per year are performed at
Ninewells.
Nuclear Medicine: Aspirin enhanced DTPA scans provide measurements
of renal function in each kidney and the glomerular filtration rate of both
kidneys. This can be helpful in diagnosing renal artery stenosis.
Community
Most cases of raised blood pressure are detected in primary care and 95%
are also managed by primary care physicians. Hospital referral occurs:



To find out if the patient really does have raised blood
pressure
Where raised blood pressure is difficult to control
Where there is a secondary cause of raised blood pressure.
At the hypertension clinic at Ninewells about 10 new patients with raised
blood pressure are seen every week.
Ethics
Health promotion and
Disease prevention
Ethical issues include equity in treatment. There has been a tendency not to
treat the elderly although there is dramatic benefit in treating raised blood
pressure in older patients. There is evidence that in mildly raised blood
pressure we stop one stroke for 870 years of patient treatment.
Be aware of variation in prevalence and mortality due to hypertension and
how these can be prevented. Adherence and compliance to treatment can
be a problem. There have been a number of trials over the past 40 years
looking at the optimum treatments for patients with high blood pressure.
Problem as seen by the Doctor
Raised Blood Pressure
Problem as experienced by your patient
System links
Cardiovascular/Endocrine
What a doctor will be able to do:
1
2
3
4
5
6
7
How was your patient identified and what relevant examination was carried out on their
initial presentation.
Measurement of blood pressure with a mercury/anaeroid sphygnomanometer
Ambulatory blood pressure monitoring
What investigations did your patient undergo looking for end organ damage?
What is the incidence of raised blood pressure in Tayside? Relate this to the incidence of
stroke and heart disease in Tayside
What lifestyle advice did you give your patient and how was this received? What were his
changeable and unchangeable risks
What are the current guidelines of the British Hypertension Society for the treatment of
raised blood pressure?
How do these differ from the SIGN guidelines?
How a doctor approaches their practice:
8
9
10
Relate the common therapeutic options to their underlying mechanism of action.
How do the following influence your decision to treat:
Age
Gender
Existence of other disease processes
What factors in the history contribute to the decision to treat?
Doctor as a professional:
11
12
Who should be involved in the long-term follow up of such patients so that we can ensure
optimal treatment? What is the “Rule of Halves”?
Under what circumstances is the decision made to refer patients for further investigations.
Do you understand that sometimes hypertension results from another disease: when should
this be investigated?