Poorly Controlled Hypertension

Nurudeen S. Bello; Peter Ekanem; Natasha Istifo; and Joelle McBain

Background:

This case is designed for second year medical students, but could also be used for nursing and pharmacy students. This is a case of man whose overall wellness is impacting the control of his hypertension. Students should initially work through his diagnosis of hypertension, including management, and then move on to addressing his wellness issues.

Day One:

Mr. Harris is a 50-year-old man who presents to your Internal Medicine clinic after being referred by his Family Doctor for poorly controlled hypertension.

Tutor Probes:

  1. What is the definition of hypertension?
  2. Classify hypertension. What are the causes of hypertension?
  3. Discuss the epidemiology of hypertension in Canada
  4. What is the prevalence of hypertension?
  5. What symptoms does hypertension cause?
  6. How is hypertension diagnosed?
  7. How would you investigate hypertension?
  8. What risk factors including lifestyle predispose to hypertension?
  9. When is it considered “poorly controlled”?
  10. What is hypertension a risk factor for?
  11. What other risk factors are you concerned about in this patient?

Wrap up Questions:

  1. What questions would you need to ask Mr. Harris on history?
  2. What elements on physical exam would be important?
  3. What is “white coat” hypertension? How do you determine this?

Day Two:

Mr. Harris is an office assistant in a financial firm who initially presented with a blood pressure of 160/120mg, with a pulse rate of 100bpm. ECG showed features of left ventricular hypertrophy. He was diagnosed with hypertension five years ago, for which he was given two different antihypertensive medications (Ramipril, and HCTZ). However, his blood pressure is still not well controlled. He is a known smoker with 30 pack-year history. He started drinking about 3 to 4 bottles of beer per day after he separated from his wife three years ago. His BMI is 32 kg/m2. His job is mostly sedentary, and he is not involved in any form of exercise. He has a positive family history of hypertension.

Tutors probes: 

  1. Define the following terms: hypertensive urgency; hypertensive emergency; and masked hypertension.
  2. Is Mr. Harris’s BMI significant?
  3. What is the significance of smoking and alcohol intake in Harris’ current health problem?
  4. How is hypertension usually managed?
  5. Is his management appropriate? Why or why not?
  6. Are there any lifestyle changes that Mr. Harris needs to make?
  7. List the members of the team necessary in the management of Harris’s condition?
  8. What is the resistant hypertension, and when is it considered resistant?
  9. What are secondary causes of hypertension?
  10. What else do you want to know regarding social history?

Wrap up questions: 

  1. What stressors do you see in his history that are impacting his lifestyle choices?
  2. How has stress affected Mr. Harris’s physiological symptoms?

Day Three: 

Mr. Harris’ physician has been worried because of his attitude towards his medications. He is not compliant with medications, as well as the recommended lifestyle changes. Since separating with his wife, he has been eating out, and mostly at McDonalds. He once told his physician that a day without fries and cheese burger is likely to be a bad one.

Ceasing smoking or alcohol consumption to him is an uphill task. He believes this helps him with his insomnia, which had been a norm since his wife moved out of the house. He has no close companions, and has seen smoking and alcohol consumption as ‘inevitable partners’.

Tutors probes: 

  1. What are the risks associated with Mr Harris’ lifestyle?
  2. Can you associate some of his attitude to his marriage?
  3. Will Mr. Harris benefit from counselling/psychiatry input?
  4. What other complications should we look out for?
  5. If you were in Mr. Harris’ position, would you agree with his lifestyle choices?
  6. What are your thoughts on Mr. Harris’ lifestyle choices?
  7. How might Mr. Harris’ lack of companions contributed to his hypertension?
  8. What could be the reasons Mr. Harris has insomnia?
  9. If someone close to you was in Mr. Harris’ position: how would you reach out to them?
  10. What are some various coping strategies for someone who has had major lifestyle changes?

Wrap Up Questions:

  1. As a Health Care Provider, how does mental health affect your ability to have a healthy lifestyle?
  2. In order to reduce stress, what needs to be done to create a healthy lifestyle change?

License

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Instructional Strategies in Health Professions Education Copyright © 2020 by Kalyani Premkumar (Instructor) and ECUR 836 is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License, except where otherwise noted.

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