Aashi
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A 64-year-old man presents to your office for his yearly physical. This is his first visit to your office, and he admits that he has not been to a physician in over a decade. He takes no medications and denies tobacco or alcohol use. He is a recently retired accountant and started "health walks" three times a week, for 45 minutes at a time. He has been keeping salt out of his diet, going to yoga classes, and trying to lose weight for the last six months. At a local mall, his blood pressure was read as 160/80 mm Hg at a free screening booth.
On physical examination, his weight is 80 kg (176 lbs), and he stands 58" tall. Blood pressure taken in the office is 154/88 mm Hg, heart rate is 74/min, and temperature is normal. The physical exam shows AV nicking on funduscopic evaluation. The EKG has normal sinus rhythm at 74/min with no ST changes. The following lab results are available:
Sodium 143 mEq/L, potassium 5.0 mEq/L, bicarbonate 24 mEq/L, BUN 10 mg/dL, creatinine 1.1 mg/dL, glucose 96 mg/dL; cholesterol (total) 210 mg/dL, HDL 50 mg/dL, triglycerides 180 mg/dL, LDL 124 mg/dL, VLDL 36 mg/dL. Urinalysis is normal.
What is the next appropriate step regarding the management of this patient?
(A) ACE inhibitor
(B) Atenolol and simvastatin
(C) Advise further lifestyle modification and recheck blood pressure in 4 to 6 weeks
(D) Hydrochlorothiazide
(E) Repeat the blood pressure
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| prathapdoctor
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i will go with C.
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| sarika
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AV nicking start (D) Hydrochlorothiazide
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| CocaCola
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agree with sarika
D - Hydrochlorothiazide
Also potassium is a little high...
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| robin082006
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the requirement for diagnosing hypertension needs at least 2 times of measurement by medical professional service.
This patient has 1 only, but funduscopic exam indicates complication of chronic hypertension. We need to try lifestyle modification and confirm the diagnosis firstly so I go with C
But still hesitate about D.
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| Guptashutosh
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c
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| star1
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(D) Hydrochlorothiazide is CORRECT!!!!!!!
(A) ACE inhibitor
Cant be use as there is Hyperkalemia
(C) Advise further lifestyle modification and recheck blood pressure in 4 to 6 weeks
He is already doing these lifestyle chances but still over weight
(E) Repeat the blood pressure
BP has been checked just in office so no need for recheck
So left with options B & D
B cant help him in lowering K so D seem to be the right answer
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| MDcooper
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pt already has complications from HTN ie av nicking.2 diff settings show he has HTN.He has been trying on life style modifications.I will diagnose him as a pt of hTN and start treatment on this appoitment with diuretics.
One quesry though.HDL>40,total cholesterol <200,and TG =? is considered normal????
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| star1
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| Aashi
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(D) Hydrochlorothiazide
Explanation:
This patient has sufficient evidence to clinically define hypertension. Although there have only been two readings, he has physical evidence of long-standing hypertension in the AV nicking on the funduscopic examination. Repeating the blood pressure is not necessary.
For isolated systolic hypertension, first-line medical therapy would be a diuretic. He comes to you having already tried to alter his lifestyle in terms of exercise, sodium restriction, and weight loss for the last six months. Even though he has an elevated cholesterol, the mortality benefit of the diuretics far outweighs any concern about increasing his lipid levels with the thiazide. An ACE inhibitor is recommended as first-line therapy for patients with diabetes, congestive heart failure, or persons postmyocardial infarction with systolic dysfunction. Beta-blockers are currently recommended as first-line therapy for patients who are postmyocardial infarction or who have known coronary disease. Simvastatin is not necessary because the patient has an LDL of <130 mg/dL and no evidence of coronary disease. His risk factors are his age (>45 years) and being a male with hypertension. Statins are used in patients with two or more risk factors if diet and exercise do not get the LDL under 130 mg/dL.
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