CASE NO# 1

HYPERTENSION

PATIENT PRESENTATION:
John Davis (J.D.) is a 52-year-old American man, who complains
of a throbbing headache in the morning for the past week. He
was diagnosed with hypertension 6 years ago and was initially
treated with lifestyle modifications, and then with
antihypertensive medication (amlodipine). He took this
medication for 2 years and then discontinued it because he did
not think it was needed. Past medical history is unremarkable.
J.D.'s father had hypertension and died of an MI at age 54. His
mother had diabetes and hypertension and died of a stroke at
age 68.
J.D. has been married for 20 years and has two sons who are
healthy. He smokes 1 pack per day of cigarettes (for 35
years) .He occasionally drinks alcohol (1-2 drinks per week).He
thinks that his BP is high because of job-related stress. He does
not believe that he has hypertension. J.D. states that he does not
engage in any regular form of exercise and does not restrict his
diet in any way.
Physical examination shows he is 69 tall, weighs 108 kg (BMI
35.2 kg/m2)
BP is 148/88 mm Hg (left arm) and 150/86 mm Hg (right arm)
while sitting, heart rate is 82 beats/min and regular, Temp .
37.1oC .
One month ago, his BP values were 152/88 mm Hg and 154/84
mm Hg. Funduscopic examination reveals mild arterial
narrowing, arteriovenous nicking, with no exudates or
hemorrhages. The remainder of the physical examination is
essentially normal.
Laboratory examination:
K 4.0 mEq/L
Na 143 mg/L
Cl 101 mg/L
BUN 24 mg/dL
SrCr 1.3 mg/dL
glucose 95 mg/dL
uric acid 8.0 mg/dL
ALT 28U/L
AST 35U/L

Therapeutic I

HTN case

Fast Lipid Profile

LDL 140 mg/dL
HDL 35 mg/dL
TG 230 mg/dL
TC 198 mg/dL

UA:Yellow, Clear, pH 5.5, (-) protein, (-) glucose, (-) ketones, (-) blood, (-) nitrite ,
no bacteria

ECG and chest radiograph reveal mild LVH.

QUESTIONS:
Problem Identification
a. What is the proper assessment of J.D.'s hypertension based on this
information?
b. Based on the guidelines from JNC VII ,classify this patient's
hypertension.?
c. Why is J.D.at high risk for hypertension-related complications?
d. What forms of target organ damage are present in J.D.?

Desired Outcome:
a. List the goals of treatment for this patient.

Optimal Plan:
a. Outline specific lifestyle modification for this patient.
b. Which treatment principles need to be considered when choosing an
initial antihypertensive agent for J.D.?

Follow-up Question
a. Suppose the patient now complains of intolerable adverse effects due
to the current antihypertension drug therapy. Outline an appropriate
change to her current therapy.
b. Suppose the patient is tolerating the current drug therapy but has not
achieved the desired Bp control. Outline an appropriate change to her
current therapy.

Patient Education
a. What information about hypertension, and antihypertensive therapy
you should provide to this patient.?
b. Describe how you would explain to a patient how to use
sphygmomanometer?

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HTN case

Outline the change ,if any you would make to the phrmacotherapeutic
regimen for this patient if he had present at the initial visit with each of the
following characteristics:
African-American descent
10 year history of asthma
History of angina pectoris
Diabetes mellitus
A pregnant woman

Therapeutic I

HTN case