Hypertension

Question 1

Approach to young hypertension:
- List all the causes of hypertension
(and where to rule out)

Answer 1

Primary hypertension (commonest but unlikely in PACES)

Secondary hypertension
Renal
1. CKD (hx, ix)
2. Nephritic syndrome (hx, ix)
3. Polycystic kidney disease (pe)
4. Renal artery stenosis (pe)

Endocrine
1. Hyperaldosteronism (ix)
2. Cushing’s syndrome/disease (pe, ix)
3. Acromegaly (pe, ix)
4. Phaeochromocytoma (hx, ix)
5. Hypothyroidism (hx, pe, ix)

Vascular
1. Coarctation of aorta (pe, vitals, ix)

Rheumatologic
1. Scleroderma renal crisis (pe, ix)
2. Takayasu arteritis (hx, pe, ix)

Others
1. Pre-eclampsia (in women) (hx, ix)
2. OSA (hx, ix)
3. Drugs - stimulants, recreational drugs (hx, ix if needed)

Question 2

History taking in hypertension

Answer 2

1. Onset, duration of hypertension, BP range
2. Current treatment, response and side effects
3. Other comorbidities
4. Target organ damage
   - TIA / stroke
   - Blurring of vision / transient blindness
   - Angina, IHD, MI, heart failure
   - Proteinuria, haematuria, urine output
   - Sexual dysfunction - ED
5. Family history of: hypertension, CVS, end organ damage, inheritable conditions
6. Social history
   - Smoking, alcohol
   - Physical activity, weight
   - Diabetes
7. Secondary hypertension screening*

Question 3

Screening questions for secondary hypertension

Answer 3

Renal
1. Frothy/bubble urine, haematuria, reduced urine output
2. Family history of CKD, haemodialysis

Endocrine
3. Weight gain and obesity - Cushing, hypothyroidism
4. Sweaty palms - Acromegaly
5. Change in appearance or ring/shoe/hat size
6. Specific region of blurring of vision (bitemporal hemianopia)
7. Paroxysmal headache, palpitations, sweating - Phaeo
8. Lethargy, cold intolerance - hypothyroidism
9. Menorrhagia (in women) - hypothyroidism

Rheumatologic
10. Change in finger colour in response to temperature
11. Giddiness or syncope with upper limb activity

Others
12. Loud snores, apnoea, daytime somnolence - OSA
13. Stimulant or recreational drug use
14. Pregnancy and missed period - pre-eclampsia

Question 4

Screening examination for hypertension

Answer 4

1. Gross inspection - lesions, clues, syndromes
   - Look at the front and back
2. Radial-radial or radial-femoral delay (CoA)
3. Offer fundoscopy - Lisch nodules, hypertensive retinopathy
4. Thyroid examination
5. Chest deformities
6. Apical deviation, murmurs
7. Abdominal masses - ballotable renal masses, organomegaly
8. Abdominal bruit
9. Pedal oedema
10. Neurological deficit from stroke

Question 5

Formulating action plan for approach to hypertension?

Answer 5

1. Involvement of multidisciplinary team
2. Admissions when necessary for further investigations
3. BP control
4. Management and prevention of complications
5. Lifestyle modifications - smoking, alcohol cessation, exercise, weight loss
6. Follow up appointment