high blood pressure consultation Flashcards
what should you ask in the history?
- Check BP values - what was it?
- Measurement: when, how, where (clinic or ambulatory)
- Sx of high BP: chest pain, headache, visual change (eg blurring), shortness of breath, dizziness
- Assess modifiable risk factors (remember them in pairs):
1. Smoking and alcohol
2. Diet (salt and fatty food) and weight (and recent changes)
3. Exercise (frequency, duration, type) and occupation (Sedentary? Stress?)
what is the association between high blood pressure and gout?
High blood pressure is another major risk factor for gout. It gets complicated, though, because the diuretics taken to lower high blood pressure increase uric acid levels, so the treatment as well as the disease is associated with gout
what things are important to cover in the pmhx?
MI, stroke, angina. DM, gout. High blood pressure or cholesterol
what things can you cover in the dhx?
- take any medications
- anything for high bp specifically
- have you made any lifestyle changes previously
what things should you cover in the fhx?
MI, stroke, angina. Diabetes, high cholesterol
what things should you check in the shx?
is anyone else at home with you? Do you have good social support? Stressed?
what should you examine in the patient?
- BP,
- BMI and waist circumference
- Feel pulses and listen to carotids and the heart
- Abdomen (eg renal masses, renal bruit)
- Fundoscopy
what investigations are important to do?
bedside:
QRISK2, ECG and urine ACR (albumin: creatinine ratio)
bloods: Lipid profile (fasting sample is not needed), U+E, HbA1c
special tests:
Consider optician review for eye changes
how would you talk to someone about the possible diagnosis of high blood pressure?
At this point it is possible that you have high blood pressure, or hypertension
What do you already know what this is?
- It’s is often not clear what the cause of high blood pressure is. We call this essential hypertension
- This rarely has any Sx, but if untreated, it increases your risk of heart attacks and strokes
- We need to do more investigations to confirm whether you have high BP. I would therefore like to arrange a 24-hour test of your BP. This will involve wearing a BP cuff with a small monitor which measures you BP at intervals throughout the day and night. Is that alright?
- In not possible, do HBPM. 2 consecutive seated measurements 1 min apart. Record BD for 4 days (preferably 1w)
what to say if they say….. do i need medication for my blood pressure?
At this stage we don’t know for sure whether you have high BP, so I can’t say whether or not you will need to take medication to lower your BP, like ramipril or amlodipine
Lifestyle alone if stage 1 HTN and QRISK < 20%
Anti-hypertensive if stage 1 HTN and QRISK ≥ 20%, stage 2 (clinic BP >160/100) TOD, established CV disease, renal disease or DM
what lifestyle advice can you give about htn?
Smoking cessation. Most important. NHS stop smoking phone number or discuss in pharmacy
Limit alcohol to 14 units a week, with 2 alcohol free days (6 pints of beer or 6 standard size glasses of wine)
DASH diet (Dietary Approaches to Stop Hypertension. High in fruit, veg and unsaturated fat. Low in saturated fat and sugar). Also reduce salt. Refer to dietician
Weight. A health BMI is between 18.5 - 25kg/m. Yours is…Weight loss group such as slimming world are available free on the NHS
Exercise. 30mins moderate exercise 5 times a week (increased breathing, able to talk). Reduce the time spent sitting. Consider group exercise class
Manage stress eg mindfulness
how does lipids relate to hypertension?
If QRISK is 10% or more, optimise modifiable risk factors where appropriate before offering a statin (atorvastatin 20mg). If they are just over 10, then they should certainly start with lifestyle modification before a statin; explain that it is a long term medication and the benefit is likely to be small
Offer statin without risk assessment for those with T1DM, chronic kidney disease or familial hypercholesterolaemia
Before starting, measure: lipids, LFT, U+E. HbA1c, TFT and CK
how does glucose relate to htn?
Information eg Diabetes UK
Mention that they can see the diabetic nurse specialist
Offer DESMOND (Diabetes Education for Self-Management for Ongoing and Newly Diagnosed) programme to patient and their family
Diet is the cornerstone of Rx (see diet sheet from Diabetes UK. A diabetic diet is a healthy diet). Also see lifestyle changes above
If HbA1C is still high despite diet and lifestyle, start metformin first line. If CI, then use a sulfonylurea (eg gliclazide). Combine if HbA1c is still high
how to close the consultation?
Any questions
Mention the importance of NHS health checks every 5 years if aged 40-74
FU in 4 weeks
SN: palpitations, chest pain, shortness of breath
