Group: 2
Student Names: Victoria Genoch, Tim Grainger, Gul-e-Rana, Chan Nguyen,
Olena Riabova, Katie Riddle, Juela Sejdo, Celina Wu
Case: Hypertension
Template for Case Workup:
Instructions:
 Please fill in the following information in the header:
o group number
o student names
o case topic
 Please save the document according to the format:
o 2015_CaseWorkup_CaseTopic_GroupX
o Example: 2015_CaseWorkup_Hypertension_Group1
Step 1
Identify The Problem Or Diagnosis That Requires Treatment
Question 1: What is your assessment related to the management of HYPERTENSION?
(Note: fill in the blank with the topic of the week)
Prompting questions:
 What is the issue or problem?
 Is the problem related to drug or a disease?
 Does the problem require intervention?
 Tip: focus on stating the issue or problem from the case. In the past some student groups documented all the
background subjective and objective information from the case. This is unnecessary. Remember marks are
given for being clear and concise.
Ms. Zaleski is an 83 y.o. woman who comes to the clinic for follow-up, and reports dizziness over the past
few months. She reports that her recent BP readings (since October 2014) have been ~120/80mmHg. It was
around this time that she had changed from ibuprofen to acetaminophen, and when the dizziness began. She
has had no falls, and no other associated symptoms. In order to address the patient’s concerns of dizziness,
and prevent falls, her current medications (pain and antihypertensive drug therapies) must be examined and
may require adjustment.
Step 2
Identify All Potentially Effective Options
Question 2: What are all potentially effective options to treat the patient?
Please list the options below in bullet format
Drug
Options







Stop all antihypertensive medications
Stop amlodipine
Stop hydrochlorothiazide (HCTZ)
Change dosage of amlodipine
Change dosage of HCTZ
Change to taking q.hs (as opposed to to q.am)
Add medication (e.g.: fludrocortisone) to treat dizziness.
Page 1 of 6
Group: 2
Student Names: Victoria Genoch, Tim Grainger, Gul-e-Rana, Chan Nguyen,
Olena Riabova, Katie Riddle, Juela Sejdo, Celina Wu
Case: Hypertension
NonDrug
Options





Continue with healthy diet (low sodium, Mediterranean)
Dizziness prevention (rising slowly, maintaining hydration, compression stockings)
Avoid grapefruit juice due to interaction with calcium channel blockers (CCBs)
Increase amount of exercise regimen
Continue to abstain from alcohol and smoking
Add more rows as needed
Step 3
Choose The Best Treatment Plan For The Individual Patient
Question 3: What is your treatment plan? Remember to justify your plan.
Prompting questions
 Why did you choose this treatment plan?
 Why did you rule something else out?
 The following factors may help you choose or rule out therapy:
o Indication
o Efficacy: NNT, ARR etc,
o Safety: Contraindications, Precautions, Side Effects, Drug Interactions
o Dose and Duration (for both efficacy and safety)
o Adherence Factors: Convenience, Cost, Coverage, Patient Concern
o Overarching Consideration: Patient health goals and preferences
Plan
Reduce dosage of HCTZ
Reduce dosage of amlodipine
Take anti-hypertensives q.hs
Dizziness prevention
- Rising slowly in stages (supine –
sit – stand)
- Maintain hydration, avoid
overnheating
- Use compression stockings
Rationale
Currently patient is taking 50 mg of hydrocholorthiazide that
provides no additional benefit regarding CV events, mortality and
BP reduction. Recommend reduce dose to 12.5mg and titrate
accordingly as low dose thiazide diuretics followed by ACEI
reduce mortality and adverse outcomes in patients more than 80
years old. (HYVET study). Sodium and potassium levels are also
borderline, which could be caused by HCTZ and resolved by
reducing the drug.
It’s important to reduce all anti-hypertensive medications as pt is
well below target (sBP <150mmHg), however tapering down of
anti-hypertensive medications is essential to avoid complications in
the elderly. 2.5mg is the recommended initial dosage for elderly
Taking BP medication at bed time are associated with lower mean
asleep systolic and diastolic BP, a lower prevalence of a nondipping pattern, a higher prevalence of controlled ambulatory BP
and a lower risk of total CVD events and fewer overall deaths
(MAPEC study)
Simple lifestyle modification can lead to increase effective plasma
volume, maintain blood supply to vital organs and prevent
dizziness and further risk of fall.
Page 2 of 6
Group: 2
Student Names: Victoria Genoch, Tim Grainger, Gul-e-Rana, Chan Nguyen,
Olena Riabova, Katie Riddle, Juela Sejdo, Celina Wu
Case: Hypertension
Continue with low sodium,
Mediterranean diet
Abstain from alcohol, smoking
Increase exercise 4x/wk, 3060minutes each time
Education re: warning signs/
symptoms of HTN
Ruled Out
Discontinuing all anti-hypertensive
medications
Stop HCTZ
Add medication (e.g.:
fludrocortisone) to treat dizziness
These are all good non-drug options to help manage hypertension
and prevent CV events.
Continue with Spring Senior Exercise Program.
To encourage patient to remain actively involved in the
management of her health and to optimize her safety.
Rationale
Stopping both medication simultaneously may lead to high blood
pressure putting her at increase risk of CV events, stroke and other
complications. Ibuprofen use may have also been a contributing
factor.
Thiazide diuretics are the first line treatment in elderly patient to
treat hypertension due to effective reduction in CV events and
stroke (HYVET study).
Since patient is having dizziness, most likely due to hypotension
caused by multiple antihypertensive drug therapy/ increase dose it
is not wise to continue these medicine and treat her dizziness by
other measures.
Add more rows if needed
Step 4
Develop a Monitoring Plan for the Individual Patient
Question 4. What are your goals of therapy for this patient?
Tips:
 You may wish to resolve the patient’s undesirable signs and symptoms.
 You may wish to prevent complications of a disease state or condition
 Make sure your goals are specific to the individual patient as this will help you develop a monitoring plan
 In real life practice you would involve the patient in determining the goals based on their preferences
Broad Goal: reduce the risk of cardiac, cerebrovascular and renal complications associated with chronic
HTN, reduce the risk of fall, and try to maintain patient independence with a convenient treatment plan
Specific Goal: Target BP of systolic BP <150mmHg and to treat her dizziness and prevent future
occurrences
Question 5: What is your monitoring plan for this patient? Fill in the table below.
Tips
 Remember to choose specific monitoring parameters.
 For Efficacy:
o How will you know if the goals of therapy are achieved?
o How will you know if patient is getting better?
o How will you know if patient is getting worse?
 For Safety:
o What are common side effects?
Page 3 of 6
Group: 2
Student Names: Victoria Genoch, Tim Grainger, Gul-e-Rana, Chan Nguyen,
Olena Riabova, Katie Riddle, Juela Sejdo, Celina Wu
Case: Hypertension
o What are rare but serious side effects?
o How will you detect if these side effects occur?
 For Time-frame
o When will you monitor the efficacy or safety parameter?
o How often will you repeat the monitoring?
 For Who is Responsible:
o Who will be responsible for monitoring the efficacy or safety parameter
o Examples: Patient, PA, RN, Pharm, MD
 For Threshold For Change:
o What will be your threshold for changing your plan if
 A) Goals are not achieved (ie the therapy is not effective)
 B) The patient experiences side effects?
 What will you do next?
Monitoring
Parameter
(Be specific)
Efficacy
Community BP
monitoring
Follow-up appt
Time-frame
Who is
Threshold for Change
Responsible Additional Comments
q.1-2 wks, post
exercise
In 4wks
Patient, pharm
Cardiac
complications (e.g.:
MI, angina)
Daily, on-going Pt, PA/MD,
pharmacist
Cerebrovascular
complication (e.g.:
stroke, TIA)
Daily, on-going Pt, PA/MD,
pharmacist
Blood work for
In 4wks, then
serum K+, lipids and q. 3-6 months
blood sugar
PA/MD
PA/MD
Target systolic BP of <150 (CHEP 2014
guidelines)
F/u re: dizziness, falls, medication side-effects.
If dizziness persists, consider workup to rule
out other causes of dizziness:
- ECG for bradycardia
- Echocardiogram for aortic stenosis
- TSH for hypothyroidism
- CBC for anemia
Monitor for:
- chest pain/discomfort
- SOB
- pain/discomfort in one or both arms, back
of neck, jaw or stomach
- Nausea
- Sweating
If any of these symptoms occur, call 911
Monitor for:
- Headache
- Blurred vision
- Trouble speaking
- Weakness
If any of these symptoms occur, call 911
If serum K is more than 5, stop
hydrochlorothiazide and add up either ACEI or
potassium sparing diuretics
Page 4 of 6
Group: 2
Student Names: Victoria Genoch, Tim Grainger, Gul-e-Rana, Chan Nguyen,
Olena Riabova, Katie Riddle, Juela Sejdo, Celina Wu
Case: Hypertension
Safety
Symptoms of
hypotension
Daily, on-going Pt, PA/MD
pharmacist
Side-effects of
medications
Daily, on-going Pt, PA/MD,
pharmacist
Monitor for signs
and symptoms of
gout (sudden onset
of severe joint pain
and swelling)
Drug interactions
Daily, on-going Pt, PA/MD,
pharmacist
Daily, on-going Pt, PA/MD,
pharmacist
If despite lowering the dose of HCTZ patient
is still experiencing dizziness, consider
 further lower/stop the thiazide diuretic
 lower the dose of amlodipine
Check for dizziness, tachycardia, headaches,
rash, flushing, constipation, increased joint
pain. Remember to avoid grapefruit juice
Check uric acid levels and stop thiazide diuretic
if suspecting gout.
Advise patient to always provide her doctor
with the list of medication she is taking to
avoid DI. PA to review drug Hx before writing
a new medication. Encourage pt to only go to
one pharmacy to minimize risks.
Add more rows as needed
Page 5 of 6
Group: 2
Student Names: Victoria Genoch, Tim Grainger, Gul-e-Rana, Chan Nguyen,
Olena Riabova, Katie Riddle, Juela Sejdo, Celina Wu
Case: Hypertension
Step 5
Write the Prescription
Question 6: What will you document on the prescription?
Primary Care Associates
123 Wellness Road, Anytown, Canada, (123) 456-7890
Name: _Klara Zaleski___ Date: __Jan 31, 2015___
Address: 145 Daffodil Way, Toronto ON, M2R 4K2___
Hydrochlorothiazide 12.5mg p.o., one tablet q.hs x 30days
(NOTE: change in dosage, for treatment of HTN)
Dispense: Thirty tablets
Refills: Three
Amlodipine 2.5mg p.o., one tablet q.hs x 30 days
(NOTE: change in dosage, for treatment of HTN)
Dispense: Thirty tablets
Refills: Three
Calvin Harris
Calvin Harris PA #19873
As per medical directive #4A
Adam Knowitall
Dr. Adam Knowitall, MD, FMRPC, CPSO 139583
Page 6 of 6