doc_clotaire
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A 53-year-old investment banker comes to the office for a routine health screening appointment. He made the appointment at the insistence of his wife, who has been concerned about his health ever since his father died of a heart attack at the age of 60. He denies any medical problems and does not take any medications. His only problem has been stress at work. He does remember being told many years ago that his blood pressure was borderline. He took his blood pressure at a health fair in his neighborhood grocery store 2 weeks ago and it was 145/95 mm Hg. Looking back in his previous medical records from 10 years ago, this patient's systolic blood pressure has ranged from140 to 150 mm Hg and his diastolic blood pressure has ranged from 80 to 95 mm Hg. The patient is overweight and has gained 6.8 kg (15 lbs) since his last visit 10 years ago. His blood pressure today is150/90 mm Hg. The most appropriate management at this time is to
A. advise him to eat a no salt diet and exercise at least 1 hour daily
B. advise him to take his blood pressure once a day at home and to return to the office in 6 months
C. advise him to try to find less stressful employment
D. prescribe an antihypertensive medication
E. schedule a follow-up appointment in 2 weeks to repeat his blood pressure
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| sandra
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d
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| nyimalay
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I would choose D.
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| Korotkoff
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why not A?
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| anuba
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D. Had hx. of mild to mod. HTN for 10 yrs., positive FHx.of heart attack(father)
That's why I chose D.
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| dr_arc
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A. advise wt loss, wt loss corelates directly with drop n bp.
the pt has had mild/mod Ht for some time now but without any intervention so far.wt loss fails then next step meds.
tempted to choosed meds because of long h/o elevatred BP readings but then again protocol calls for nonpharmac measures first.so my guess is A-though no added salt would have sounded better than a no salt at all.
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| equinoxe
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E? confirm HTN dx - his previous visit was 10y ago and supermarket bp check is not reliable
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| docnikki
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I would choose A.
a trial of low salt and wt loss will likely to lower his BP and the protocall calls for the same...before meds are started if BP is lower than 160/90, non pharmac management is tried.
Even if we want to confirm his high BP in next visit, it is still reasonable to advise non pharmac measures as the best next step.
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| sandra
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i would've chosen A, had it been a "low" salt diet n exercise. but the option given is "no" salt diet which is not warranted, as i understand..correct me if im wrong.
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| Ivonne
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A
Start medication only if lifestyle modification have proved insufficient to control blood pressure.
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| arlete
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A
He's a virgin in terms of treatment, we always start with lyfestyle modification, when the BP is not very very high.
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| DrVirgo
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Dx of HTN is BP > 140/90 on three separate occations two weeks apart ........
so........
i think........
E?E. schedule a follow-up appointment in 2 weeks to repeat his blood pressure
.......I don't know if the non-office BP reading counts
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| Korotkoff
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Yes, it counts. In this case scenario, his previous medical records show that he had hypertension. IMO, no need of repeat BP measurement for diagnosis.
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| DrVirgo
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docnikki wrote:
I would choose A.
a trial of low salt and wt loss will likely to lower his BP and the protocall calls for the same...before meds are started if BP is lower than 160/90, non pharmac management is tried.
Even if we want to confirm his high BP in next visit, it is still reasonable to advise non pharmac measures as the best next step.
I'm tempted to choose A too, but I'm thrown off by "NO" salt and
"at least 1 hour" exercise... Isn't that a bit too much for this overweight man?...
Shouldn't we recomment a "LOW" salt diet and at least "20-30 min" of exercise to start as lifestyle modification?
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| Justice
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E... if confirmed, go with A
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| doc_clotaire
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Wao , I am so impressed to see the BIG TIME DOCS hammering this HTA question . This question is from Step 3 kaplan q-bank , I screwed it up too ...that s why I post it here
Explanation:
The correct answer is D
. This patient has documented hypertension based on multiple blood pressure measurements which demonstrate a systolic blood pressure of 140 mm Hg or greater and a diastolic blood pressure of 90 mm Hg or greater. In fact, his hypertension dates back at least 10 years according to his prior medical records. The treatment of hypertension is multifactorial. This patient had long-standing high blood pressure as well as family history of death from myocardial infarction. These factors put him at increased risk of complications from hypertension such as stroke and heart attack.He should be immediately started on antihypertensive medications, encouraged to exercise in moderation, and he should try to reduce the stress at work.
A salt free diet and daily exercise (choice A) are not realistic suggestions for many patients. Moderate changes in diet and physical activity are more likely to be initiated and continued. This patient has long-standing hypertension as well as a family history of heart attack. These factors put him at increased risk for complications from hypertension and his high blood pressure should be treated medically. Lifestyle changes in diet and exercise will help reduce this patient's risk of developing complications, but are often insufficient on their own to adequately treat hypertension. Daily blood pressure measurements and a return visit in 6 months(choice B) are not appropriate for this patient. Hypertension is often diagnosed on 2 separate elevated blood pressure measurements. This patient has had long-standing hypertension according to his past medical records and he does not need further diagnostic workup. He should be started on antihypertensive medications immediately. Changing a job to reduce stress (choice C) is not a realistic suggestion for most patients. Blood pressure goes up in all people during periods of stress or exercise. But avoiding stress will not prevent high blood pressure. High blood pressure can occur in anyone, even those people that are calm and relaxed. Although stress management is an important integral aspect of the patient's overall health, it is insufficient to treat hypertension. He should be started on antihypertensive medications immediately. A follow-up appointment in 2 weeks to repeat blood pressure (choice E) is the appropriate step in a patient who has an elevated blood pressure reading for the first time. The diagnosis of hypertension is often made on 2 separate elevated readings. Sometimes, patients are asked to take their blood pressure at home and return with a log of the measurements over a course of a week. This is not an appropriate option for this patient as he has already had multiple documented elevated blood pressure measurements. He has confirmed hypertension and should be treated immediately with antihypertensive medications.
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| equinoxe
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Nice one, thank you for challenging us 
Do you think solving step 3 questions (qbank or/and uw) are useful for step 2 ck prep? I have checked a few and they seemed very similar to the step 2 q approach, but I wonder wheter it really helps or it's just my impression...
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| arlete
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Thank you, doc_clotaire, very good, tricky one! 
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| doc_clotaire
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Equinoxe
I am currently preparing for step 3 right now , you see ...... but I remember doing some of them while I was preparing for CK . You are right , they are pretty similar but step3 focus more on long term management . My advice to you is to do them only if you have extra time , otherwise stick to UW CK .
You are welcome arlete , I know this sucker is tricky , I myslef picked A and it screwed me up BIG TME too 
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| dr_arc
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thank you doc clotaire..this was a really good one. keep them coming.
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| nyimalay
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Thank you very much. Please keep it up.
Good luck with Step 3.
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