First Diagnosis of Hypertension

Dr R: It looks like our first patient this morning is Mrs J. We have some time to talk because she isn’t back in the room yet. She is a very nice 38-year old woman who came in for an annual physical about 3 months ago. At that time she had an elevated blood pressure. So she is here today to see how her blood pressure is doing.

MS3: Is she on any medication for her pressure?

Dr R: That raises the question: what does it take to make the diagnosis of hypertension? That was the first elevated blood pressure that we have documented, and she does not check it outside of our office usually.

MS3: Doesn’t she have to have at least two blood pressures checked at different visits to be diagnosed?

Dr R: Right. It is based on the average of properly done blood pressure readings on at least three different visits.

MS3: Oh, and the cuff needs to be the right size too, or that can affect the readings.

Dr R: And try to check the blood pressure after the patient has been sitting in a quiet environment for at least 5 minutes. Very good. So what blood pressure reading would be considered hypertension?

MS3: A systolic of 140 or higher and a diastolic of 90 or higher.

Dr R: Are those numbers different for someone with diabetes or chronic?

MS3: Yes, it goes lower to 130 and 80.

Dr R: Very good. Lucky for Mrs J she has been healthy and has no medical conditions. You asked previously if I started medications with Mrs J. No, we discussed hypertension and what it means. She is worried about it because both her parents had hypertension, and her mother also had diabetes and high cholesterol. So at the last visit we talked about things she could do to decrease her blood pressure. Can you tell me a few of those?

MS3: Well, a healthy diet is always a good place to start. And exercise. Does she smoke or drink alcohol or even do any recreational drugs?

Dr R: Very good. Let’s start with a healthy diet. What does that mean?

MS3: I guess less salt and more fruits and vegetables.

Dr R: That is a good guess. Cutting back on salt does help. So does eating a diet rich in fruits, vegetables, and low-fat dairy products. Hopefully when she is eating these, she is also reducing the foods that have lots of saturated and total fat. This is known as the DASH diet and has been known to reduce a person’s systolic blood pressure by 8–14 mmHg.

MS3: That’s more of a change than I thought.

Dr R: But diet changes are difficult to do and may take time to get used to. We will see in a few minutes how she is doing. So that leads us to exercise. How much exercise should she have?

MS3: Every day?

Dr R: It would be great if people could exercise every day. I always say: “30 minutes a day more days than not.” It doesn’t always have to be at the same time, so she can do 15 minutes during lunch and the other 15 minutes later in the day. How intense does it have to be?

MS3: The heart rate should go up to 220 minus the age?

Dr R: And shoot for 50%–85% of that number? That’s a good guideline, but it’s a bit complicated. I tell folks: “As long as you feel like you are exerting yourself, it will be helpful. When you finish exercising, you should be able to say to yourself, ‘That was good exercise.’” When she and I talked 3 months ago we also determined her BMI (body mass index) and discussed that she is overweight. She wanted to work on her diet and exercise so that she can try to get to a normal weight besides also lower her blood pressure. So, we have addressed diet and exercise, which we will go over with her again when we get in there. You also mentioned smoking, alcohol, and drugs of abuse. Why are these important?

MS3: Smoking is known to cause an elevation in blood pressure. Alcohol is good in small amounts, but too much alcohol can be bad. And I was taught to always ask about drugs of abuse.

Dr R: Yes, smoking can affect the blood pressure and so can too much alcohol. One alcoholic beverage a day for women and two for men is fine, but more than that can affect the blood pressure. You are also correct about asking about illegal drugs. Cocaine and amphetamines can cause the blood pressure to go up but so can some over the counter medications and prescription medications so it is always good to get a thorough list of all medications and herbals that a person may be taking. Now that we have that information and the vital signs from the nurse showing that she is still having elevated blood pressures, what are we going to do today for her?

MS3: Well, I guess the next step would be the physical exam.

Dr R: Good. What areas do we focus on in a patient with a new diagnosis of hypertension?

MS3: We should listen to her heart and lungs and check for edema in the legs.

Dr R: That’s a good place to start. Since high blood pressures affect the blood vessels in the body, where else would you like to examine?

MS3: Well, in the eyes would be one place. Also, the carotid arteries would be good to listen to.

Dr R: Very good. We listen to the carotids, abdomen, and femoral arteries to check for bruits. Examining the abdomen for enlarged kidneys or masses is also good along with a basic neurologic check and the pulses and edema check at the feet. The thyroid is also good to palpate since hyperthyroidism can cause hypertension. Also, we already talked a little about weight and her BMI. After doing the exam, would you want to order any tests? I ask this knowing she came in fasting this morning for labs in case she was hypertensive.

MS3: I would assume then you are getting a fasting lipid panel and maybe a BMP to check electrolytes and diabetes. Since you mentioned the thyroid, if you have any concerns about hyperthyroidism, we could check a TSH.

Dr R: Good. So we are—in general— checking physical exam or lab findings to find causes: an abdominal bruit that might reveal renovascular hypertension or a large thyroid suggesting hyperthyroidism. And we’re looking for sequelae of hypertension. Looking for atherosclerosis—carotid bruits, for example. You can also get a baseline EKG especially if we are going to start any treatments that could affect the heart rate. Other tests to consider would be a urinalysis to check for kidney disease along with the creatinine checked in the BMP. There are always other tests to do if you are concerned about another cause for the hypertension. Usually these tests will be done later if she continues to have problems with medications, or her history or physical makes you think she might have an underlying cause to her hypertension. Looks like we are well on our way to discussing this with our patient and evaluating her hypertension. Let’s go in and see her.

Ann Rodden, DO, Medical University of South Carolina, Author
Alec Chessman, MD, Medical University of South Carolina, Editor

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