Chapter 13: Hypertension: Pass the Salt, Please Level II

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LEARNING OBJECTIVES

After completing this case study, the reader should be able to:

• Classify blood pressure according to current hypertension guidelines, and discuss the correlation between blood pressure and risk for cardiovascular morbidity and mortality.

• Identify medications that may cause or worsen HTN.

• Discuss complications (eg, target organ damage) that may occur as a result of uncontrolled and/or long-standing HTN.

• Establish goals for the treatment of HTN, and choose appropriate lifestyle modifications and antihypertensive regimens based on patient-specific characteristics, comorbid disease states, and current HTN guidelines.

• Provide appropriate patient counseling for antihypertensive drug regimens.

PATIENT PRESENTATION

Chief Complaint

“I’m here to see my new doctor for a checkup. I’m just getting over a cold. Overall, I’m feeling fine, except for occasional headaches and some dizziness in the morning. My other doctor prescribed a low-salt diet for me, but I don’t like it!”

HPI

James Frank is a 64-year-old black man who presents to his new family medicine physician for evaluation and follow-up of his medical problems. He generally has no complaints, except for occasional mild headaches and some dizziness after he takes his morning medications. He states that he is dissatisfied with being placed on a low-sodium diet by his former primary care physician.

PMH

• HTN × 14 years

• Type 2 diabetes mellitus × 16 years

• COPD, GOLD 3/Group C

• BPH

• CKD

• Gout

FH

Father died of acute MI at age 73. Mother died of lung cancer at age 65. Father had HTN and dyslipidemia. Mother had HTN and diabetes mellitus.

SH

Former smoker (quit 6 years ago; 35 pack-year history); reports moderate amount of alcohol intake. He admits he has been nonadherent to his low-sodium diet (states, “I eat whatever I want”). He does not exercise regularly and is limited somewhat functionally by his COPD. He is retired and lives alone. He works at Wal-Mart and has healthcare insurance through his employer.

Meds

• Triamterene/hydrochlorothiazide 37.5 mg/25 mg PO Q AM

• Insulin glargine 36 units SC daily

• Insulin lispro 12 units SC TID with meals

• Doxazosin 2 mg PO Q AM

• Carvedilol 12.5 mg PO BID

• Albuterol HFA MDI, two inhalations Q 4–6 H PRN shortness of breath

• Tiotropium DPI 18 mcg, one capsule inhaled daily

• Fluticasone/salmeterol DPI 250/50, one inhalation BID

• Mucinex D® two tablets Q 12 H PRN cough/congestion

• Naproxen 220 mg PO Q 8 H PRN pain/HA

• Allopurinol 200 mg PO daily

All

PCN—rash.

ROS

Patient states that overall he is doing well and recovering from ...