NR 667 STUDY MATERIAL FOR GUARANTEE PASS
1. Hypertension
Presentation: Most are not symptomatic, Occipital Headaches, headache on awakening in am, burry
vision.
Look for these clinical findings to rule out organ damage:
Microvascular
ā¢Eyes (HTN retinopathy): AV nicking (causes when arteriole crosses on top of
vein), papilledema
ā¢Kidneys: microalbuminuria and proteinuria, elevated serum creatinine and abnormal
eGFR, peripheral or generalized edema
Macrovascular
ā¢Heart: S3 (CHF), S4 (LVH), carotid bruits, decreased or absent peripheral pulses
ā¢Brain: TIA or hemorrhagic stroke
Assessment/Exam:
ā¢Asymptomatic
ā¢Occipital headache
ā¢Blurry vision
ā¢Headache upon wakening
ā¢Exam of optic fundi: Look for AV nicking, hemorrhage, papilledema
ā¢LVH (long standing HTN)
ā¢Perform exam of symmetrical pulses
ā¢Auscultate for Carotid bruits, abdominal bruits, and kidney bruits
Diagnostic studies: EKG, fasting lipid profile, fasting blood glucose, TSH, CXR to R/O
cardiomegaly. CBC, CMP, and urinalysis. Measure BP 5 minutes apart. Assess the patients 10- year
risk for heart disease (ASCVD)
Diagnosis: > 140/90 mm Hg start on B/P medication.
Pharmacologic Management:
ā¢FIRST LINE DIURETIC: Hydrochlorothiazide (HCTZ) 25 mg/day
(max 50mg/day) *May worsen gout and elevate lipids and glucose
ā¢ALTERNATIVE CCB: Amlodipine besylate 5 mg /day. (Watch for lower
extremity edema)
ā¢ACE: lisinopril 10mg/day complicated HTN first line
ā¢Consider ACE/ARB in patient with DM, proteinuria, HF. CONTRAINDICATED IN
PREGNANCY
ā¢If stage 2, initiate 2 drug classes (Diuretic & CCB most effective in
African American)
Follow up:
ā¢2-4weeks
Referral:
ā¢Cardiology if EKG is abnormal
Secondary HTN causes to consider:
ā¢CKD, renal artery stenosis, hyperthyroidism, phenochromocytoma, OSA, coartication of the
heart (SBP higher in the legs), oral contraceptives, corticosteroids, cocaine, NSAID,
decongestants
Differential:
ā¢Secondary hypertension
ā¢White coat syndrome
ā¢Pregnant
ā¢Pregnancy induced hypertension
