HYPERTENSION (cont)

History• Following the documentation of hypertension, which is confirmed after an elevated blood pressure, properly measured, has been documented on at least 3 separate occasions (based on the average of 2 or more readings taken at each of 2 or more visits after initial screening), a detailed history should extract the following information:
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o Extent of target organ damage
o Assessment of patients' cardiovascular risk status
o Exclusion of secondary causes of hypertension
• Patients may have undiagnosed hypertension for years without having had their blood pressure checked. Therefore, a careful history of end organ damage should be obtained.
• A history of cardiovascular risk factors includes hypercholesterolemia, diabetes mellitus, and tobacco use (including chewing tobacco).
• Obtain a history of over-the-counter medication use, current and previous unsuccessful antihypertensive medication trials, and ethanol intake.
• The historical and physical findings that suggest the possibility of secondary hypertension are a history of known renal disease, abdominal masses, anemia, and urochrome pigmentation.
• A history of sweating, labile hypertension, and palpitations suggests the diagnosis of pheochromocytoma.
• A history of cold or heat tolerance, sweating, lack of energy, and bradycardia or tachycardia may indicate hypothyroidism or hyperthyroidism.
• A history of weakness suggests hyperaldosteronism. Abdominal bruit suggests the possibility of renal artery stenosis. Absence of femoral pulses suggests coarctation of aorta.
• Kidney stones raise the possibility of hyperparathyroidism. The presence of papilledema and other neurologic signs raises the possibility of increased intracranial pressure. A history of drug ingestion, including oral contraceptives, licorice, and sympathomimetics, should be obtained.
Physical
An accurate measurement of blood pressure is the key to diagnosis. Several determinations should be made over a period of several weeks.
At any given visit, an average of 3 blood pressure readings taken 2 minutes apart using a mercury manometer is preferable. Blood pressure should be measured in both the supine and sitting positions, auscultating with the bell of the stethoscope. On the first visit, blood pressure should be checked in both arms and in one leg to avoid missing the diagnosis of coarctation of aorta or subclavian artery stenosis.
As the improper cuff size may influence blood pressure measurement, a wider cuff is preferable, particularly if the patient's arm circumference exceeds 30 cm.
The patient should rest quietly for at least 5 minutes before the measurement.
Although somewhat controversial, the common practice is to document phase V (a disappearance of all sounds) of Korotkoff sounds as the diastolic pressure.
• A funduscopic evaluation of the eyes should be performed to detect any evidence of hypertensive retinopathy. These are flame-shaped hemorrhages and cotton wool exudates.
• Palpation of all peripheral pulses should be performed.
• Look for renal artery bruit over the upper abdomen; the presence of a unilateral bruit with both a systolic and diastolic component suggests renal artery stenosis.
• A careful cardiac examination is performed to evaluate signs of LVH. These include displacement of apex, a sustained and enlarged apical impulse, and the presence of an S4. Occasionally, a tambour S2 is heard with aortic root dilatation.
Causes
• Primary or essential hypertension (90-95%)
• Secondary hypertension: A small percentage of patients (2-10%) have a secondary cause. The following is a list of secondary causes of hypertension:
•
o Renal (2.5-6%)
 Renal parenchymal disease
 Polycystic kidney disease
 Urinary tract obstruction
 Renin-producing tumor
 Liddle syndrome
o Renovascular hypertension (0.2-4%)
o Vascular
 Coarctation of aorta
 Vasculitis
 Collagen vascular disease
o Endocrine (1-2%) - Oral contraceptives
o Adrenal
 Primary aldosteronism
 Cushing syndrome
 Pheochromocytoma
 Congenital adrenal hyperplasia
o Hyperthyroidism and hypothyroidism
o Hypercalcemia
o Hyperparathyroidism
o Acromegaly
o Neurogenic
 Brain tumor
 Bulbar poliomyelitis
 Intracranial hypertension
o Pregnancy-induced hypertension
o Drugs and toxins
 Alcohol
 Cocaine
 Cyclosporin
 Erythropoietin
 Adrenergic medications
Lab Studies• Unless a secondary cause for hypertension is suspected, only the following routine laboratory studies should be performed:
•
o CBC count, serum electrolytes, serum creatinine, serum glucose, uric acid, and urinalysis
o Lipid profile (total cholesterol, low-density lipoprotein [LDL] and high-density lipoprotein [HDL], and triglycerides)
• Additional tests described below are indicated when specific clinical situations warrant further investigation.
•
o Microalbuminuria is an early indication of hypertensive nephrosclerosis and is also a marker for a higher risk of cardiovascular morbidity and mortality. Present recommendations suggest that individuals with type I diabetes should be screened for microalbuminuria. Usefulness of this screening in hypertensive patients without diabetes has not been established.
o Plasma renin activity (PRA) is performed to detect evidence of primary hyperaldosteronism. Low renin values confirm the diagnosis of primary hyperaldosteronism; however, hypokalemia may be associated with a form of hypertension, but it is not often present.
o Determination of sensitive thyroid-stimulating hormone (TSH) level excludes hypothyroidism or hyperthyroidism as a cause of hypertension.
Imaging Studies
• Echocardiography: The limited echocardiography study, rather than the complete examination, may detect LVH more frequently than electrocardiography. The main indication for limited echocardiography is evaluation for end organ damage in a patient with borderline high blood pressure. Therefore, the presence of LVH despite normal or borderline high blood pressure measurements requires antihypertensive therapy.
• Imaging studies for renovascular stenosis: If the history suggests renal artery stenosis and if a corrective procedure is considered, further radiologic investigations are performed.
Other Tests
• Routine testing includes electrocardiograms.
• Ambulatory blood pressure monitoring: Indications for ambulatory blood pressure monitoring include labile blood pressure, a discrepancy between blood pressure measurement inside and outside the physician's office, and poor blood pressure control. Ambulatory monitoring also identifies patients who have the distinct syndrome called white coat hypertension

hay lắm, nhưng lần sau bluerose nên dịch ra tiếng Việt nhé

Dich thi can nhieu thoi gian hon! sorry nhe!