Hypertension case study # 3
Mr Brown a 62-year-old African American man with “very labile blood pressure” (BP)
for at least 11 years presents to his primary care provider’s office with the chief
complaint of having “flunked” an insurance physical. Immediately after retirement (last
month), he applied for a supplemental life insurance policy but last week he learned that
his application was refused. He feels well and has no complaints. He says that his BPs
have run “high” in the last 10 to 15 years, but always settle down when he rests for 10
minutes. He suspects that part of the reason for his denial of insurance was his BP, which
was measured in his office by the physician assistant who performed his insurance
physical as 148/98 mm Hg. He remembers that this measurement came in the middle of a
very busy day, with 3 conference calls and a very stressful “exit interview” for one of his
subordinates. He has been taking his BPs at home for the last week, and brings a printout
of the last 15 readings; the average is 151.2/90.4 mm Hg, but the range is 130/72 to
160/102 mm Hg. He says he has not visited a physician for the last 10 years or so,
because he’s been so busy with his work and his family. He brings copies of documents
describing the results of the insurance physical that he had 2 weeks ago: abnormalities
included a seated BP of 155/95 mm Hg, a glucose (allegedly fasting) of 156 mg/dL, a
serum creatinine of 1.5 mg/dL, a (random) urinary albumin/creatinine ratio of 954 mcg/g,
and an A1c of 7.8%. He was, of course, told to “discuss these results with his physician.”
He recalls being denied a supplemental disability insurance policy about 6 years ago,
allegedly based on “protein in my urine,” but didn’t follow up this abnormality. He
denies previous treatment for hypertension or diabetes. He denies prior episodes of
hypokalemia, muscle cramps, palpitations, headache, sweating attacks, visual
disturbances, polyuria, polydipsia, and fevers.
Medical History:
“Labile blood pressures” for at least 11 years (as above)
Medications:
One multivitamin tablet po daily
Allergies: No known drug allergies. He had no problems with the combination of
trimethoprim + sulfamethoxazole (taken as prophylaxis for traveler’s diarrhea for a trip to
Mexico) when he was 50 years old.
Tobacco History: Negative (ie, never used tobacco products of any kind)
Alcohol History: Typically has 5 to 6 alcoholic beverages/week, usually beer or wine,
more commonly on the weekend, or when entertaining customers in restaurants.
Drug Abuse History: Denied; said to have had negative random drug screens at work.
Family History:
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Father, aged 88, hypertension since age 62, survived a myocardial infarction (MI)
at 72
Mother, aged 87, hypertension since age 68, osteopenia, “early diabetes”
controlled with dietary measures
Brother, aged 61, no known medical problems, but “doesn’t visit doctors much”
Sister, aged 63, breast cancer at age 59, had lumpectomy and adjuvant radiation
and chemotherapy, with no evidence of disease at last follow-up
A maternal uncle died nearly 12 years ago, at age 70, after “3 miserable years” on
dialysis, said to be due to longstanding diabetes that he didn’t attempt to control
Social History:
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Happily married for the second time for the last 17 years; lives with wife and 2
teenagers in single-family dwelling in nearby suburb
Retired 4 weeks ago as vice president for finance of a local Fortune 500 company
He felt that the “stress” of his job (especially during the recent financial downturn
in the US economy) was “ruining his family life,” and therefore accepted “early
retirement” when it was offered
Volunteers 16 hours/week at the local Executive Service Corps, providing advice
to nonprofit organizations and out-of-work individuals
Coaches 15-year-old son’s baseball and 16-year-old daughter’s soccer teams on
weekends
Plans on starting 18 holes of golf twice weekly, “as soon as I have time”
Review of Systems:
Constitutional: No recent poor health, changes in weight, fatigue or headaches.
Eyes: No eye disease or injury, no blurred or double vision, and no symptoms of
glaucoma.
ENT: No hearing loss, tinnitus, earaches or otorrhea, rhinitis or sinusitis, epistaxis, oral
ulcerations, bleeding gums, bad breath, or sore throat.
Cardiovascular: No history of heart trouble, chest discomfort or other symptoms
consistent with angina pectoris, palpitations, orthopnea, dyspnea, or pedal edema.
Respiratory: No chronic or frequent cough, hemoptysis, dyspnea, or wheezing.
Gastrointestinal: No loss of appetite, change in bowel habit, nausea, vomiting, diarrhea,
constipation, hematochezia or hematemesis, or heartburn. Has gained about 20 pounds
and 2 inches in the waistline in the last 10 years, and about double that since his wedding
17 years ago.
GU: No diminution in urinary volume or frequency, polydipsia, dysuria, hematuria,
incontinence, nocturia, kidney stones.
Musculoskeletal: No joint pain, stiffness or swelling, weakness of muscles or joints,
muscle pain or cramps, back pain, or cold extremities.
Skin: No rash, pruritus, change in color of skin, hair or nails, varicose veins, breast pain
lumps or discharge, sun exposure, or skin lesions.
Neurological: No major headaches, lightheadedness, dizziness, seizures, dysesthesias,
tremors, or head injury.
Psychiatric: No memory loss or confusion, nervousness, depression, or insomnia.
Endocrine: No “hormonal” problems, thyroid illness, polydipsia, polyuria, heat or cold
intolerance, or xerodermia.
Hematologic: No problems recovering after cuts or bruises, anemia, phlebitis, or swollen
lymph nodes.
Physical Examination:
Well-developed, well-nourished man in no acute distress.
Height: 66 inches, weight: 224 pounds, BMI = 36.2 kg/m2, waist circumference = 42 in.
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Supine BP readings:
o Right: 150/94 mm Hg, pulse is 76 beats/minute, and regular
o Left: 148/92 mm Hg, pulse is 72 beats/minute, and regular
Seated BP readings:
o Right: 150/92 mm Hg, pulse is 76 beats/minute, and regular
o Left: 148/94 mm Hg, pulse is 80 beats/minute, and regular
Standing BP readings:
o Right: 156/98 mm Hg, pulse is 84 beats/minute, and regular
o Repeated after 2 minutes: 150/90 mm Hg, with a pulse of 76 beats/minute
and regular
HEENT: The sclerae are white, and the conjunctivae clear. PERRL. Fundi show Grade I
hypertensive retinopathy on the Keith-Wagener-Barker scale. The ears harbor no scars,
lesions, or masses; he has bilateral earlobe creases. Hearing is grossly intact bilaterally.
The pharynx is unremarkable.
Neck: Supple, without thyromegaly, lymphadenopathy, or jugular venous distension.
Lungs: Clear to auscultation and percussion bilaterally.
Cardiovascular: Regular rate and rhythm, without extra sounds, murmurs, or rubs.
There is no cyanosis, clubbing, or edema. All pulses are 2+ and equal.
Abdomen: Nontender, without organomegaly, or bruits. Rectal examination is
unremarkable.
Neurological: All cranial nerves are intact. Upper and lower extremities have 5/5
strength. Reflexes: 2+ and equal. Mental status is normal.
Laboratory results
Total cholesterol
High-density lipoprotein
cholesterol
Low-density lipoprotein
cholesterol
Triglycerides
Serum glucose (fasting)
Serum potassium
Serum BUN
Serum creatinine
eGFR
Albumin/creatinine ratio (firstvoided AM specimen)
Uric acid
Urinalysis
EKG
150 mg/dL
50 mg/dL
78 mg/dL
110 mg/dL
132 mg/dL
3.9 mEq/L
29 mg/dL
1.5 mg/dL
50 mL/min/1.73 m2
987 mg/g
8.2 mg/dL
Normal except 2+ protein, 1+ glucose, negative
microscopic exam
Normal
1. Define hypertension for adults and children. (10 points)
2. Identify target BP goals in treatment for you patient above what would your target
BP be? (10 points)
3. Describe the evaluation for an initial clinical visit for hypertension. (10 points)
4. Identify common secondary causes for hypertension, and include the appropriate
diagnostics to rule in/out (diagnostics include significant positives/negatives on
exam, labs, other testing) (10 points)
5. Identify life-style changes for management of hypertension, Be specific. What are
the expected values from each? (10 points)
6. For your patient above what is your diagnosis(es) (10 points)
7. You decide to initiate treatment. Indicate your treatment plan and rationale for
each treatment plan. For pharmacological intervention state class, mechanism of
action and possible side effects of each drug). (20 points)
8. Briefly discuss how pediatric hypertension differs from adult hypertension in
terms of common causes (both primary and secondary), assessment, treatment and
prevention? (20 points)