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E.P. 70/F, a retired government employee, widow, came to
your clinic for elevation of blood pressures.
History of Present Illness
She is currently under physical therapy for a left hip
replacement for three months now. During sessions, her initial
BP would be as high as 175/80 mmHg, and 155/70 mmHg
after the therapy. She would be experiencing headaches in the
morning, but other than that, no other symptoms were noted.
She has no previous elevations of BP prior to her surgery.
Review of Systems
(+) slight pain on left hip relieved by indomethacin cream
Rest of the ROS unremarkable
Past Medical History: unremarkable
PE: BP 186/75, HR 72 regular, RR 16. She has essentially
normal head and neck findings, lung and chest PE were
normal as well. Her heart is not enlarged and no adventitious
sounds were appreciated. Abdominal PE was normal. She has
no bipedal edema and her pulses were full and equal.
Neurologic exam were normal. However, fundoscopy finding
showed (+) copper wiring.
Labs: Crea 1.0 mg/dl, BUN 6.0, K 4.2 mg/dl, Na 143, Cl
110, HCO3 24, lipid profile normal, 12 L ECG regular
sinus rhythm, normal axis

What are the risk factors as far as the history is

Post-op patient
Physical therapy
Elevated blood pressure
History of NSAID use
Review of Systems
Pain on the left hip relieved by topical preparation
of NSAID relevant to high BP because _____
The rest is unremarkable
Past medical history, PE, and Labs
(+) copper-wiring Stage 3 Retinopathy
All labs are normal
Diagnosis: Isolated Systolic Hypertension
Diastolic is normal, only systolic is abnormal
Staging influence what you will prescribe
Indicate the stage in your impression
Why Isolated Systolic Hypertension? What is it in the
Age if the diastolic is the one thats elevated, it is
usually the younger adults that is affected; if its the
systolic thats elevated, it is more commonly
associated with increasing age
According to the guideline:
Normal systolic: 120 to 139
140/90 and above is considered hypertension

Think about your goal considering the blood pressure

and age of the patient
In the guideline, BP should be 150 (systolic) and <90
(diastolic) for 50 years old and above
For all ages, maintain a BP of <140 systolic for adults
Differentials will depend on the presenting problem of
the patient
Elevated blood pressure
Secondary hypertension
Cushings syndrome
Pheochromocytoma ruled out because our
patient is old
First you should know the pathophysiology:
preload, afterload, inotropic contractility (negative
inotropic effect)
Classify drugs: negative inotropic effect, preloaders
Determine therapeutic objectives: pharmacologic
and non-pharmacologic
Main problem: lower the blood pressure
Prevent more severe complications
Maintain normal blood pressure
Lifestyle modification
Educate the patient
Do not treat the headache anymore because when
you lower the blood pressure, the headache will be
gone and analgesics will just add to the problem
*prescribing cascade
Treat and give the P-drug
Point out the good and bad characteristics of the
o Diuretics
o CCB dihydropyridine and nondihydropyridine
o blockers
o blockers
Give prototypes
o ARB Losartan
o ACEI Captopril
o Direct renin inhibitors Aliskiren
Make a table
o Efficacy mechanism of action
o Safety side effects/adverse effects (i.e.,
Diuretics hypokalemia, orthostatic
hypotension, hyperglycemia, hyperuricemia)
o Suitability contraindications
o Cost depend on how long you told the patient
to come back
According to the guideline: 1st line treatment is
thiazide diuretic BUT we dont give this due to its
adverse effects
o Not ACE inhibitors because ____
o Not ARB because ____

o Give CCB because of its efficacy, it is a

vasodilator (the problem of our patient, the
arteries are stiff) give Amlodipine, start with
the lowest dose possible (not 5mg), once a day
for 1 week
For the non-pharmacologic treatment:
o It is not enough to just say low salt, exercise
you have to be specific on how low the salt
intake should be, and what kind of exercise to
o Tailor the plan according to the patient