Table of Contents


Brief Scenario

  • Patient Name: Ahmed Elzahrany
  • Gender: Male
  • Age: 50 years
  • Social History Snippet: Accountant, married, has 3 kids.
  • Complaint: Blood pressure measurement 160/100 mmHg (discovered at pharmacy).
  • Time: 7 minutes.

Task: What is expected from the candidate

  • Obtain focused history.
  • Order proper investigations.
  • (Implicitly, discuss findings and initial management plan)

Patient Details & Reason for Visit

  • Your Name: Ahmed Elzahrany
  • Age: 50 years
  • Reason for Visit: You measured your blood pressure at the pharmacy twice, and the pharmacist told you to consult your physician.

Information to Reveal Upon General Questioning

  • You were feeling generally well until last month when you started to feel unwell and tired.
  • Sometimes you get mild headaches, described as being around your head, which resolve by themselves.
  • Your neighbor advised you to measure your blood pressure because of these feelings.
  • You presented today to have your blood pressure measured. It was 160/100 mmHg, measured on three occasions. The nurse confirmed it was high.
  • You have no other specific complaints right now.

Social History

  • Occupation: Accountant.
  • Family: Married, have 1 daughter and 2 sons.
  • Diet: Eat fast food and junk food frequently with a lot of beverages (implying sugary drinks).
  • Caffeine: Drink 2 cups of tea and 1 cup of coffee daily.
  • Physical Activity: Do not practice any physical sports (sedentary).
  • Relationships: Relationship with wife, siblings, family, and neighbors is very good. No social problems or problems at work.
  • Smoking: Smoker, 1 pack (approx. 20 cigarettes) every day. (Candidate should quantify duration if possible, though not provided).
  • Alcohol/Illicit Drugs: (Not mentioned, assume none unless asked, should deny if asked).

Analysis of Complaint / Symptoms

  • Symptoms: Just the light, spontaneously resolving headache around the head. Specifically deny the following if asked:
    • Muscle weakness or numbness
    • Blurring of vision
    • Chest pain
    • Dyspnea (shortness of breath)
    • Palpitations
    • Dysuria (painful urination), hematuria (blood in urine), oliguria (low urine output)
    • Claudication (leg pain during walking)
    • Lower limb edema
    • Vomiting
    • Syncope (fainting)
    • Sensory or motor deficit
  • Symptoms Suggesting Secondary HTN: Specifically deny the following if asked:
    • Sleep problems (snoring, daytime sleepiness)
    • Neck swellings (goiter)
    • Heat or cold intolerance
    • Change in bowel habits
    • Tremors
    • Other endocrinal symptoms (e.g., sweating, flushing - related to pheochromocytoma)
  • Previous History:
    • No history of chronic diseases like diabetes or renal diseases.
    • Have not received any medications for this or other conditions recently.
    • Have not had any investigations performed before this visit.

Family History

  • Mother: Hypertensive and Diabetic.
  • Father: Had a myocardial infarction (MI) at the age of 53 years old.

Concerns

  • You are concerned that you might have a myocardial infarction (heart attack) like your father.

Questions to Ask the Doctor

  • “Will I need any investigations for my condition?”
  • “Doctor, I don’t feel anything (significant), why must I use medication?”

OSCE - HTN

Introduction

  • Rapport & Introduction: Build relation by smiling, introduce self clearly, confirm patient ID (name, age).
  • Communication:
    • Start with open-ended questions (e.g., “How can I help you today?”, “Tell me more about that”). Use a mix of open and closed questions appropriately.
    • Listen attentively, allow patient to finish, use pauses effectively. Use verbal/non-verbal facilitation (encouragement, silence, nodding).
    • Use concise, easily understood language; avoid or explain jargon.
    • Demonstrate interest, concern, respect throughout. Encourage the patient to talk.
  • Structure & Timing: Manage time effectively (7 minutes). Periodically summarize to verify understanding and invite corrections (“Internal Summary”).
  • Patient-Centered Approach: Elicit and address patient’s Ideas, Concerns, and Expectations (ICE). Promote informed, shared decision-making.
  • Closure: Ask if the patient has any questions, inform about the next steps/follow-up.

History Taking

HOPI

Presenting Complaint & Confirmation

  • Identify the patient’s main complaint (high BP reading).
  • Enquire about the BP readings: When, where, how many times? Confirm the reading (160/100 mmHg).
  • Explore associated symptoms the patient volunteers (tiredness, mild headache).

Rule Out Symptoms of Target Organ Damage

  • Systematically inquire about symptoms suggesting complications:
    • Neurological: Headaches (clarify character beyond ‘mild’), dizziness, visual changes (blurring, loss of acuity, blindness), weakness, numbness, syncope, sensory/motor deficits (TIA/Stroke).
    • Cardiovascular: Chest pain (angina/MI), shortness of breath (dyspnea - CHF), palpitations, leg pain on walking (claudication - PAD), lower limb edema (CHF, renal).
    • Renal: Polyuria, polydipsia (can be DM), nocturia, hematuria, oliguria.
    • Retinopathy: Visual changes (as above).
    • (will deny most of these)

Rule Out Symptoms Suggesting Secondary Hypertension

  • Inquire about symptoms pointing to underlying causes:
    • Renal: History of kidney disease, edema, changes in urination.
    • Endocrine:
      • Pheochromocytoma: Palpitations, sweating, tremor, anxiety attacks, headaches (paroxysmal).
      • Hyperaldosteronism (Conn’s): Muscle weakness (due to hypokalemia).
      • Cushing’s: Weight gain (central), skin changes (striae, bruising), muscle weakness.
      • Thyroid: Heat/cold intolerance, weight change, palpitations, tremor, neck swelling (goiter).
    • Sleep Apnea: Snoring, daytime sleepiness, witnessed apneas.
    • Coarctation: (Less likely at this age but consider) Symptoms of differential BP / leg claudication.
    • (will deny these)

Risk Factor Assessment (Modifiable & Non-Modifiable)

  • Non-Modifiable:
    • Age (50 years - increased risk).
    • Gender (Male - generally higher risk pre-menopause).
    • Family History (Positive - see below).
    • Ethnicity (Ask if relevant locally).
  • Modifiable:
    • Smoking (* 1 pack/day* - quantify pack-years if possible).
    • Diet (* High fast food/junk food, beverages* - assess salt, fat, sugar intake).
    • Physical Inactivity (* No sports*).
    • Alcohol Intake (Ask quantity/frequency - likely denies).
    • Stress (Assess work/life stress - denies significant problems).
    • Obesity (Assess via BMI later).
    • Dyslipidemia (Assess via investigations).
    • Diabetes Mellitus (Assess via investigations - denies history).

Past HX

Lifestyle Assessment

  • (Partially covered in Risk Factors) Confirm details on:
    • Diet (Salt intake, fat intake, fruit/veg intake).
    • Exercise (Type, frequency, duration).
    • Smoking (Quantify).
    • Alcohol.
    • Caffeine intake (* 2 tea, 1 coffee*).
    • Recreational drug use.

Past Medical History & Co-morbidities

  • Ask about previous diagnosis of HTN or high BP readings.
  • Ask specifically about known chronic illnesses: Diabetes, Kidney disease, High cholesterol, Heart disease (MI, Angina, CHF), Stroke, Peripheral Artery Disease. (denies DM, renal disease).

Medication History (Including HTN-Inducing Drugs)

  • Current medications (prescription, OTC). (denies).
  • Past medications.
  • Allergies.
  • Specifically ask about drugs that can raise BP: NSAIDs, Steroids (oral/inhaled), Oral Contraceptive Pills (OCPs), Decongestants, certain herbal remedies, substance abuse.

Family History (Detailed)

  • Hypertension (* Mother*).
  • Diabetes Mellitus (* Mother*).
  • Premature Cardiovascular Disease (MI or Stroke <55 yrs in male relative, <65 yrs in female relative) (* Father MI at 53* - Significant).
  • Kidney disease.
  • Other chronic diseases.
  • Sudden death.

Social History

  • Occupation (* Accountant* - assess for stress).
  • Marital Status (* Married*).
  • Family Structure (* 3 children*).
  • Living situation.
  • Social support system (* Good relationships*).
  • Stressors (Work, financial, family - denies major issues).

Conclusion

Patient’s Perspective (ICE) & Impact

  • Ideas: What does the patient think is going on? Why now?
  • Concerns: What worries the patient most? (* Fear of MI like father*).
  • Expectations: What does the patient hope to achieve from the visit? (Initial prompt was BP check).
  • Impact: How are the symptoms (tiredness, headache) or the high BP reading affecting daily life?

Clinical ExaminationY

  • General Appearance: Note body habitus, fat distribution (central obesity?), skin lesions (striae?), signs of distress.
  • Vital Signs & Anthropometry:
    • Blood Pressure: Measure in both arms, seated, appropriate cuff size, after 5 min rest. Repeat measurement. Consider standing BP if symptoms suggest postural hypotension (though not typical here).
    • Heart Rate & Rhythm.
    • Respiratory Rate.
    • Temperature.
    • Weight & Height to calculate BMI.
    • Waist Circumference & Neck Circumference (especially if suspecting metabolic syndrome/sleep apnea).
  • Fundus Examination: Check for hypertensive retinopathy (AV nipping, hemorrhages, exudates, papilledema).
  • Neck Examination: Palpate thyroid (goiter), auscultate for carotid bruits.
  • Cardiovascular Examination:
    • Palpate apex beat (displacement suggests LVH).
    • Auscultate heart sounds (S4 gallop?), murmurs.
    • Auscultate abdomen for renal artery bruits, palpate for aortic aneurysm/pulsation, enlarged kidneys.
  • Respiratory Examination: Auscultate lung fields (rales suggest CHF).
  • Extremities:
    • Palpate peripheral pulses (radial, femoral, pedal). Check for radio-femoral delay (coarctation).
    • Check for lower limb edema.
  • Neurological Assessment: Brief assessment if symptoms warrant (e.g., focal weakness).

Investigations

  • Initial / Routine Investigations:
    • Blood Tests:
      • Complete Blood Count (CBC - check for anemia/polycythemia).
      • Urea, Electrolytes (Sodium, Potassium - important for hyperaldosteronism/diuretic use), Creatinine (for eGFR - assess kidney function).
      • Fasting Blood Glucose (FBG) and/or HbA1c (rule out/diagnose diabetes).
      • Lipid Profile (Fasting - Total cholesterol, LDL, HDL, Triglycerides).
      • Serum Uric Acid (baseline, risk factor).
      • Liver Function Tests (LFTs - baseline before certain meds).
      • Thyroid Stimulating Hormone (TSH - rule out thyroid disease).
    • Urine Tests:
      • Urinalysis (dipstick for blood, protein, glucose).
      • Urine Albumin-to-Creatinine Ratio (ACR) (early marker of kidney damage).
    • ECG (Electrocardiogram): Look for evidence of Left Ventricular Hypertrophy (LVH), ischemia, previous MI, arrhythmias.
  • Further Investigations (If indicated by initial findings/suspicion of secondary HTN):
    • Ambulatory BP Monitoring (ABPM) or Home BP Monitoring (HBPM) - (confirm diagnosis, rule out white coat HTN).
    • Renal Ultrasound.
    • Endocrine workup (e.g., plasma renin/aldosterone, urinary metanephrines).
    • Echocardiogram (assess LVH, cardiac function).

Management Plan (CRAPRIOPS Framework & General Principles)

  • Correct False Beliefs / Clarify Diagnosis & Psychoeducation:
    • Explain the diagnosis: Based on readings (e.g., “Your blood pressure readings of 160/100 put you in Stage 2 Hypertension”).
    • Explain what hypertension is: A persistent elevation of BP, often asymptomatic (“silent killer”).
    • Explain the risks: Increased risk of heart attack, stroke, kidney disease, eye problems if untreated.
    • Address the patient’s concern about MI. Validate the concern given family history but explain treatment reduces this risk.
    • Address the patient’s question: Explain why medication is needed even without symptoms – to prevent future complications.
    • Reassure it’s common and manageable.
  • Risk Assessment: Briefly explain that factors like age, family history, smoking, and the BP level itself contribute to overall cardiovascular risk.
  • Advice / Agree on Plan / Shared Decision Making:
    • Explain the management options involve lifestyle changes and usually medication at this stage.
    • Encourage the patient to participate in decisions. Check understanding and agreement.
  • Prescription / Pharmacological Management:
    • Indication: Explain that Stage 2 HTN (≥160/100) generally requires medication alongside lifestyle changes.
    • Choice: Discuss initial options. Common strategies for Stage 2 include starting two drugs at low dose OR starting one drug and titrating/adding quickly if needed. Classes include:
      • ACE inhibitor (e.g., Ramipril) or ARB (e.g., Losartan) - often good first-line.
      • Calcium Channel Blocker (CCB - e.g., Amlodipine).
      • Thiazide-like Diuretic (e.g., Indapamide, Chlorthalidone).
      • (Beta-blockers generally not first-line unless specific indication like post-MI or heart failure).
    • Counseling: Explain the chosen medication(s), how they work simply, potential side effects (common ones), importance of adherence, that they don’t cure but control HTN.
  • Investigations: Explain the purpose of the ordered tests (baseline health, check for causes/damage, guide treatment). Address patient’s question about needing investigations.
  • Options / Non-Pharmacological Management (Lifestyle Modification): Crucial
    • Weight Loss: Advise aiming for a healthy BMI (if overweight/obese).
    • Diet: Recommend DASH diet (Dietary Approaches to Stop Hypertension) - high in fruits, vegetables, whole grains, low-fat dairy; reduced saturated/total fat. Sodium restriction (<2.3g/day, ideally <1.5g/day). Reduce intake of fast food, processed food, sugary drinks.
    • Physical Activity: Advise regular aerobic exercise (e.g., brisk walking) for at least 150 minutes/week (e.g., 30 mins, 5 days/week).
    • Smoking Cessation: Strongly advise quitting, offer support/resources (nicotine replacement, counseling).
    • Alcohol Moderation: Advise limiting intake (if applicable).
    • Stress Management: Discuss techniques if stress is a factor.
  • Plan / Follow-Up:
    • Schedule a follow-up appointment, e.g., in 2-4 weeks, to:
      • Review BP measurements (encourage home monitoring if possible).
      • Check results of investigations.
      • Assess medication tolerance/side effects.
      • Monitor adherence.
      • Reinforce lifestyle advice.
    • Explain the need for long-term monitoring and management.
  • Safety Netting / Referral:
    • Advise patient on when to seek urgent medical attention (e.g., symptoms of chest pain, stroke).
    • Mention indications for specialist referral (see below), though likely not needed initially unless investigations reveal secondary cause or BP is resistant.

Referral Indications

  • Resistant hypertension (uncontrolled on 3+ drugs including a diuretic).
  • Suspected secondary hypertension requiring specialist workup.
  • Hypertensive emergency/urgency (very high BP with acute target organ damage).
  • Significant end-organ damage requiring specialist input (e.g., severe CKD, heart failure).
  • Unusual BP variability or diagnostic uncertainty.
  • Need for specialized procedures.
  • Severe hypertension requiring same-day specialist review (e.g., clinic BP ≥180/120 mmHg with signs/symptoms or papilledema).

Adherence Strategies

  • Simplify regimen (once-daily dosing, combination pills).
  • Educate patient on importance and risks of non-adherence.
  • Use reminders (pill boxes, apps).
  • Involve family if appropriate.
  • Address side effects promptly.
  • Regular follow-up and reinforcement.

HTN Knowledge Base

Definitions & Classification

  • Hypertension Definition: Persistent SBP and/or DBP levels above which harm and increased morbidity/mortality occur if untreated.
  • Stages (based on Clinic BP):
    • Stage 1: 140/90 to 159/99 mmHg (or ABPM/HBPM average 135/85 to 149/94 mmHg).
    • Stage 2: 160/100 to 179/119 mmHg (or ABPM/HBPM average ≥150/95 mmHg).
    • Stage 3 (Severe): Clinic BP ≥180 mmHg systolic or ≥120 mmHg diastolic.
  • Elevated BP: 120-129 mmHg systolic AND <80 mmHg diastolic.

Blood Pressure Measurement

  • Standardized Technique: Requires attention to patient (rested, seated, arm supported), equipment (validated device, correct cuff size), and examiner technique.
  • Home Blood Pressure Monitoring (HBPM): Used for diagnosis and monitoring. Average ≥135/85 mmHg considered elevated. Typically duplicate readings, morning/evening, for 7 days (discard first day).
  • Ambulatory BP Monitoring (ABPM): 24hr monitoring (e.g., every 15-30 mins awake, 30-60 mins asleep). Better predictor of CV risk than office BP. Normal average daytime <135/85 mmHg. Indications include suspected white coat/masked HTN, resistance, nocturnal HTN suspicion, assessing variability, high-risk patients, etc.

Specific HTN Types

  • Isolated Systolic HTN: SBP ≥140 mmHg and DBP <90 mmHg. (Common in elderly; Thiazides or CCBs often preferred).
  • White Coat HTN: Elevated BP in clinic, normal outside (diagnosed via HBPM/ABPM).
  • Masked HTN: Normal BP in clinic, elevated outside (diagnosed via HBPM/ABPM).
  • Resistant HTN: BP above target despite 3+ drugs (including a diuretic) at optimal doses, OR controlled BP requiring 4+ drugs. Management involves confirming adherence, ruling out secondary causes, optimizing diuretic (e.g., chlorthalidone/indapamide), considering aldosterone antagonists (spironolactone).
  • Postural Hypotension: Systolic BP fall ≥20 mmHg (or diastolic ≥10 mmHg) on standing. Review meds, measure standing BP, consider referral if persistent symptoms.

Secondary Causes of HTN

  • Renal: Chronic Kidney Disease (CKD), Renal Artery Stenosis.
  • Endocrine: Primary Aldosteronism (Conn’s), Pheochromocytoma, Cushing’s Syndrome, Thyroid disease (hyper/hypo), Hyperparathyroidism.
  • Cardiovascular: Coarctation of the Aorta.
  • Other: Obstructive Sleep Apnea (OSA), Medications (NSAIDs, OCPs, steroids, decongestants, etc.), Chronic alcohol abuse.

Management in Special Conditions/Groups

  • Diabetes Mellitus (DM): ACE inhibitors (ACEi) or Angiotensin Receptor Blockers (ARBs) recommended, especially with albuminuria/CKD.
  • Chronic Kidney Disease (CKD): ACEi or ARBs are preferred (monitor K+ and creatinine).
  • Coronary Artery Disease (CAD): Beta-blockers and ACEi/ARBs preferred.
  • Heart Failure (HF): Diuretics, Beta-blockers, ACEi/ARBs, Aldosterone antagonists have demonstrated efficacy.
  • Stroke/Cerebrovascular Disease: ACEi/ARB often combined with CCB or thiazide-like diuretic for secondary prevention.
  • Atrial Fibrillation (AF): Beta-blockers or non-dihydropyridine CCBs (verapamil, diltiazem) for rate control.
  • Pregnancy: Methyldopa, Labetalol, Nifedipine (CCB) are common choices. ACEi/ARBs are contraindicated.
  • Older Age (>65 years): Treat similarly but start low, go slow. Avoid drugs increasing fall risk (e.g., alpha-blockers, potentially loop diuretics if causing volume depletion/postural symptoms). Isolated systolic HTN common.

Complications / End-Organ Damage

  • Cardiovascular: Left Ventricular Hypertrophy (LVH), Heart Failure (HF), Coronary Artery Disease (CAD - Angina, MI), Atrial Fibrillation.
  • Cerebrovascular: Stroke (Ischemic/Hemorrhagic), Transient Ischemic Attack (TIA), Vascular Dementia.
  • Renal: Chronic Kidney Disease (CKD), End-Stage Renal Disease (ESRD).
  • Retinopathy: Hypertensive Retinopathy (hemorrhages, exudates, papilledema).
  • Peripheral Artery Disease (PAD).

Screening

  • Screening recommended for all adults ≥18 years. Frequency depends on initial BP and risk factors (e.g., annually if higher risk or BP near threshold, every 3-5 years if low risk and normal BP).
  • Screen individuals with risk factors (obesity, DM, family hx), pregnant women, those with suggestive symptoms or related conditions (CVD, CKD).