Family Medicine · Year 3 · from Family Medicine

Case 1: New Diagnosis of Hypertension

Patient Demographics

  • Age: 45 years old
  • Sex: Male
  • Occupation: Software engineer

Chief Complaint

"My blood pressure was high at the company health screening. They said I need to see a doctor."

History of Present Illness

Mr. David Chen is a 45-year-old man who presents after a workplace health screening revealed blood pressure of 156/98 mmHg. He has never been told he has high blood pressure before but admits he rarely sees doctors. He denies headaches, visual changes, chest pain, or shortness of breath. He reports occasional stress-related headaches that resolve with acetaminophen. He drinks 3-4 cups of coffee daily and admits to a high-sodium diet with frequent restaurant meals.

Past Medical History

  • No known medical conditions
  • No prior surgeries
  • Last physician visit: 5 years ago for a sinus infection

Family History

  • Father: Hypertension, had stroke at age 62, survived
  • Mother: Hypertension, type 2 diabetes
  • Brother: Hypertension, age 48

Social History

  • Never smoker
  • Alcohol: 2-3 beers on weekends
  • Married with two children
  • Sedentary lifestyle, sits at desk 10+ hours daily
  • High work stress, often works late

Physical Examination

  • Vital Signs: BP 152/96 mmHg (right arm), 148/94 mmHg (left arm), HR 78, BMI 29
  • General: Well-appearing, mildly overweight
  • HEENT: Fundoscopic exam normal, no AV nicking or hemorrhages
  • Neck: No carotid bruits, no thyromegaly
  • Cardiovascular: Regular rate and rhythm, no murmurs, PMI not displaced
  • Lungs: Clear bilaterally
  • Abdomen: Soft, no bruits
  • Extremities: No edema, normal pulses

Clinical Image

Image: Proper blood pressure measurement using a sphygmomanometer and stethoscope, demonstrating the auscultatory technique essential for accurate diagnosis and monitoring of hypertension.

Image Source: Wikimedia Commons Attribution: Steven Fruitsmaak, CC BY-SA 3.0 URL: https://commons.wikimedia.org/wiki/File:Sphygmomanometer%26Stethoscope.jpg

Outpatient Workup

  • Office BP measurements (3 readings, averaged): 150/94 mmHg
  • Home BP monitoring diary (2 weeks): Average 146/92 mmHg
  • Basic metabolic panel: Normal (Creatinine 1.0, K+ 4.2)
  • Fasting lipid panel: Total cholesterol 228, LDL 148, HDL 42, Triglycerides 190
  • Fasting glucose: 108 mg/dL
  • Urinalysis: No protein
  • ECG: Normal sinus rhythm, no LVH

Assessment and Diagnosis

  1. Stage 2 hypertension - BP consistently ≥140/90 mmHg on home monitoring
  2. Hyperlipidemia - Elevated LDL, low HDL
  3. Prediabetes - Fasting glucose 100-125 mg/dL
  4. Overweight - BMI 29
  5. High cardiovascular risk - 10-year ASCVD risk 8.2%

Management Plan

Blood Pressure Confirmation:

  • Home BP monitoring confirmed elevated readings
  • Stage 2 hypertension warrants pharmacotherapy plus lifestyle modifications

Pharmacotherapy:

  • Start lisinopril 10mg daily
  • ACE inhibitor chosen given prediabetes (renal protection potential)
  • Alternative: ARB if ACE-I cough develops
  • Recheck BP and potassium/creatinine in 2-4 weeks
  • Goal BP: <130/80 mmHg

Lifestyle Modifications:

  • DASH diet counseling (rich in fruits, vegetables, whole grains, low-fat dairy)
  • Sodium restriction <2300 mg/day (ideally <1500 mg)
  • Reduce caffeine intake
  • Regular aerobic exercise: 30 minutes most days, 150 minutes/week
  • Weight loss: Target 5-10% body weight
  • Limit alcohol to ≤2 drinks/day
  • Stress management techniques

For Hyperlipidemia:

  • Calculate 10-year ASCVD risk: 8.2% (intermediate risk)
  • Discuss moderate-intensity statin therapy (atorvastatin 20mg)
  • Focus on lifestyle first with reassessment in 3 months

For Prediabetes:

  • Lifestyle intervention primary approach
  • Consider Diabetes Prevention Program referral

Follow-Up

  • Return in 4 weeks to reassess BP and medication tolerance
  • If not at goal, increase lisinopril or add second agent (thiazide diuretic)
  • Repeat labs in 3 months (lipids, glucose, renal function)
  • Annual cardiovascular risk reassessment

Teaching Points

  1. Proper BP measurement: Use correct cuff size, patient seated quietly for 5 minutes, arm supported at heart level, average of 2-3 readings. Out-of-office measurements (home or ambulatory) are recommended to confirm diagnosis.
  1. BP classification (2017 ACC/AHA):
  • Normal: <120/80 mmHg
  • Elevated: 120-129/<80 mmHg
  • Stage 1: 130-139/80-89 mmHg
  • Stage 2: ≥140/90 mmHg
  1. Treatment thresholds: Stage 2 hypertension warrants immediate pharmacotherapy plus lifestyle. Stage 1 hypertension may trial lifestyle first if ASCVD risk <10%.
  1. First-line medications: ACE inhibitors, ARBs, thiazide diuretics, and calcium channel blockers are all appropriate first-line agents. Choice may be guided by comorbidities.

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