Hypertension Recitation Case 2023
Setting: ambulatory care clinic
Chief Complaint: “I’m here to follow up on my blood pressure.”
HPI: Ginger Snaps is a 52-year-old Indigenous woman of Hispanic descent who returns to clinic today to follow-up on her blood
pressure. Her last visit was 1 month ago after not coming in for 24 months due to the COVID-19 pandemic (despite being vaccinated,
was still very nervous about leaving the house). Her blood pressure was noted to be 162/97 mm Hg. She admitted to not checking her
blood pressure at home recently and was asked to start checking again and record her readings at home. Relevant laboratory workup
was also done at the visit. She has returned to the office today to follow up on the blood pressure.
Therapeutics: What is the purpose of home blood pressure monitoring? How should it be done properly?
A somewhat nervous woman, Ginger arrives in the office today with a printout of her home blood pressure readings which shows the
following results (reports has been checking in morning):
Day 1: 152/87 mm Hg
Day 2: 159/91 mm Hg
Day 3: 148/88 mm Hg
Day 4: 155/85 mm Hg
Day 5: forgot
Day 6: 159/92 mm Hg
Past Medical History
Asthma
HTN
Obesity
Anxiety/depression
Chronic back pain
Pathophysiology: What are the 2 factors that determine BP? What causes hypertension?
Therapeutics: Could this patient be having white coat hypertension? Why/why not? What stage hypertension does this patient have?
What are the implications for the treatment of her hypertension?
Family History
Father had a stroke at age 61; mother passed away due to complications related to diabetes. Sister (age 55) also has hypertension and
diabetes.
Social History
Lives with husband
Works for an insurance company – has been allowed to work from home since start of COVID
Admits to not being as active since quarantine began and “munching” on food throughout the day (i.e. chips, pretzels). Has been
ordering food more than cooking at home. When cooks, likes to make foods from her culture (empanadas, chicken fajitas, etc)
Smokes ½ pack/day
Alcohol consumption: 1-2 glasses of wine with dinner
Caffeine consumption: 2-3 cups/day
Therapeutics: Which lifestyle modifications should this patient implement to help lower her blood pressure? List them in order from
most effective to least effective for lowering BP.
Allergies: none
Meds
Chlorthalidone 25 mg po daily
Venlafaxine XR 150 mg daily
Albuterol inhaler PRN shortness of breath
Symbicort 80/4.5 twice daily
Ibuprofen 600 mg twice daily for pain
Pharmacology: Which of her medications might be contributing to her increased BP and explain how?
Medicinal chemistry: What class of diuretics do hydrochlorothiazide, chlorthalidone and amiloride belong to? Compare and contrast
the SAR of these drug classes.
ROS: Occasional back pain, happening at random times; no c/o sensory loss, or visual changes No dysuria, flank pain, hematuria,
pedal edema, chest pain. SOB occurs 1-2 times/week, needing to use rescue inhaler
Physical Examination
Gen: The patient is an obese Indigenous woman of Hispanic descent (Birth sex: female; Gender identity: woman)
VS: BP 164/94 mm Hg, HR 92, RR 18, T 37.5°C; Wt 185, Ht 5′3″ BMI 32.8
Lungs/Thorax: Clear, breath sounds normal
CV: Heart sounds normal, no murmurs, no bruits
Abd: Soft NT/ND
Neuro: A & O × 3
Labs (1 month ago, Fasting)
Urea Nitrogen (BUN)
Serum creatinine (SCr)
Sodium
Potassium
Chloride
CO2
Glucose
Calcium
Hemoglobin A1C
Total cholesterol
HDL
LDL (direct)
Triglycerides
Reference Range
6-23 mg/dL
0.5-1.1 mg/dL
135-145 mmol/L
3.5-5.2 mmol/L
96-108 mmol/L
22-30 mmol/L
<100
8.5-10.5 mg/dL
< 5.7 (preDM) 6.5% (DM)
< 200 mg/dL
> 45 mg/dL
Individualized
< 150 mg/dL
Result
24
1.1
140
4
102
24
120
9.9
5.7 %
204
27
145
157
Urinary albumin/creatinine
ratio (UACR)
TSH
< 30 mg/g creatinine
25
0.5-5 mcg/dL
1.1
Pathophysiology: What is the relationship between Type II DM and hypertension?
Therapeutics: Which drug class(es) would be reasonable to add to her regimen and why?
Assessment:
1. Uncontrolled hypertension
2. Obesity
3. Anxiety
4. Asthma
Use the table below to guide you in identifying the subjective and objective findings, creating an assessment with rationale, making
an appropriate recommendation/intervention, describing the goal of therapy/therapeutic endpoint and determining monitoring
parameters for each of the health-related problems. (Remember to Use the Pharmacist Patient Care Process: 1) Collect and
Assess Information (Pertinent findings); 2) Develop and implement Care Plan (Recommendations/Interventions & Goal of
Therapy/Therapeutic Endpoint); 3) Follow-up: Monitor and Evaluate (Efficacy& Safety/Toxicity)
Healthrelated
problems
Subjective or
objective
findings
What evidence
from the case
support the
therapeutic
problem?
Goal of Therapy/
Therapeutic Endpoint
Recommendation
/ Intervention
Efficacy
Safety / Toxicity
Health-related problems
Hypertension
Monitor
BP in one
month
The following are prescriptions that you, as the pharmacist, must assess and determine whether the patient should continue or
stop the medication, or adjust the medication dose.
For this part of the table, identify if you would dispense each medication, your justification, and what recommendation /
intervention should be made / taken.
Medication Orders
Continue? Stop? Adjust?
Justification and/or Recommendation /
Dispense or not dispense
Intervention
Chlorthalidone 25 mg po daily
Venlafaxine XR 150 mg daily
Albuterol inhaler PRN shortness
of breath
Symbicort 80/4.5 twice daily
Ibuprofen 600 mg twice daily for
pain
Therapeutics: Recommend a drug and dose that would be acceptable to add to her regimen and state why?
Olmesartan 20 mg daily was added to her regimen.
Medicinal chemistry: Discuss the SAR of Olmesartan compared to ACEIs.
Pharmacology: Compare Olmesartan to Lisinopril in mechanism and ADEs.
Therapeutics: In whom might a DHP CCB be recommended to manage HTN?