CARDIOLOGY

Take a focused history from a patient with hypertension to include past medical history, drug history, family history and social history. You should note that hypertension is unlikely to be the presenting complaint of patients admitted to hospital, and often patients may not consider themselves to have hypertension if their blood pressure is well controlled on treatment.

Explore with the patient:

• When and how was their hypertension diagnosed?

• Do they have any symptoms or features

• What treatment(s) have they tried and what effect(s) or side effect(s) did they have?

• Has the patient experienced any complications from hypertension?

• Has the patient got any other significant cardiovascular risk factors? You may wish to calculate the patient's QRISK score.

Document your findings from the history and examination in a systematic manner. You may want to use a local clerking proforma or have a look at this useful summary from Geeky Medics.

Have a look at the patient's vital signs chart from their admission. Note down their highest and lowest blood pressure readings and make a rough assessment of the patient’s average readings. How does this compare to their target blood pressure?

Consider:

• What factors might be affecting the patient’s blood pressure at present? Write down as many as you can think of.

• What might be the risks of starting or adjusting blood pressure medications during an inpatient admission?

• What options are available for adjusting the patient's antihypertensive medication at present? (if applicable)

Consider, in a patient presenting with hypertension, what bedside tests or initial investigations might be useful to assess for complications?

Have a look through the patient's notes to see if you can find any of the investigations required. Can you find any evidence of complications?

Consider:

• What the distinction between primary (essential) and secondary hypertension?

• List as many causes of secondary hypertension as you can.

• What investigations might be required to assess for secondary causes of hypertension? What investigations has this patient had to assess for secondary causes? (You may need to access GP records or historical blood/investigation results to find out).

• When should you investigate a patient for secondary causes of hypertension?

Review the patient’s medication chart and make a note of their medication. Highlight any antihypertensive medications and make a note of their class/action.

• Can you recall 1-2 side effects of each of these drugs?

• Is the patient taking any other medications which may inadvertently raise or lower blood pressure? Highlight these too and make a note of their indication(s).

Access the relevant local or national guidelines for the management of hypertension such as the NICE 2019 Guidelines. Using this as a guide, consider the management steps available to this patient if their blood pressure was not controlled on current treatment.

Consider:

• How do each of these medications lower blood pressure?

• What are the side effects or risks of each medication?

• How should their effects be monitored after initiation of treatment?

1. https://litfl.com/left-ventricular-hypertrophy-lvh-ecg-library/

2. https://app.pulsenotes.com/medicine/cardiology/notes/hypertension

3. https://qrisk.org/three/

4. https://www.nice.org.uk/guidance/ng136/resources/visual-summary-pdf-6899919517