General Data: R.

B, 44 years old, male, married, Filipino, Born

Again Christian, born on January 31, 196, !urrently
residing at 1" Anti#ue $t. Bago Bantay, %ue&on City
sought !onsult 'or the 'irst time at our institution on
(ar!h ), **+.
Chief Complaint: heada!he
History of Present Illness:

1 day prior to !onsultation, patient e,perien!ed heada!he.
-eada!he is not aggra.ated by any 'a!tors, o!!urring at any time o' the day,
des!ribed as pulsating in !hara!ter, lo!ali&ed in the temporal area, non/
radiating, tolerable, lasting 'or appro,imately an hour and relie.ed by rest
and sleep. -eada!he is asso!iated 0ith nape pain and not asso!iated 0ith
.omiting, blurring o' .ision, numbness, loss o' !ons!iousness, diaphoresis,
di&&iness, di''i!ulty o' breathing, !hest pain, impaired memory and slurring
o' spee!h. 1atient sel'/medi!ated 0ith metoprolol tartate 23eoblo!4 )*5mg
and 6itamin B/!omple, 'or heada!hes 0hi!h a''orded no relie' o' heada!he.
1ersisten!e o' heada!he prompted patient to see7 !onsult at our institution.
Interval History:
3 years prior to !onsultation, patient e,perien!ed heada!he.
-eada!he is not aggra.ated by any 'a!tors, des!ribed as pri!7ling in
!hara!ter, non/radiating, lo!ali&ed in the temporal area, tolerable, o!!urring
sporadi!ally, lasting 'or appro,imately 3*/minutes, at e.ery other month
inter.als. -eada!he is asso!iated 0ith nape pain. -eada!he is not asso!iated
0ith .omiting, diaphoresis, di&&iness, di''i!ulty o' breathing, !hest pain,
blurring o' .ision, numbness, 0ea7ness, impaired memory or slurring o'
spee!h. -eada!he is relie.ed by rest and sleep. 1atient sel'/medi!ated 0ith
para!etamol 2Biogesi!4 0hi!h a''orded temporary relie' o' heada!he. 3o
!onsult done and heada!he persisted.
1 year prior to !onsultation, patient e,perien!ed same symptoms as
des!ribed abo.e 0ith heada!hes lasting 'or an hour long o!!urring e.eryday.
8n!rease in number o' heada!he episodes prompted !onsult at (C9
-ospital. 1atient 0as diagnosed as hypertensi.e and pres!ribed the
'ollo0ing maintenan!e medi!ation by attending physi!ian:
(etoprolol 23eoblo!4 )* mg5tablet, ;<
Aspirin +* mg5table, ;<
As!orbi! A!id tablet, ;<
6itamin B !omple,, ;<.
Past Medical History:

1atient is a 7no0n hypertensi.e, diagnosed in **" at (C9
-ospital and !urrently ta7ing the 'ollo0ing maintenan!e medi!ations 'or
!hroni! !ondition:
(etoprolol 23eoblo!4 )* mg5tablet, ;<
6itamin B !omple,, ;<
1atient does not monitor blood pressure e.eryday. =atest blood
pressure monitoring 0as ta7en (ar!h 4, **". -ighest B1 is 14*51** mm
-g and usual B1 13*59* mm -g.
1atient denies to ha.e diabetes mellitus, !ardio.as!ular disease,
pulmonary tuber!ulosis and asthma.
1atient has ne.er been hospitali&ed or had surgery. 1atient !laims
not to ha.e allergies to any 'ood or drugs.
1atient has had !omplete !hildhood immuni&ations and had
!hildhood illnesses su!h as !hi!7en po,, mumps, measles.
Family History:
2>4 -13, both parents 2>4 asthma, mother 2/4 1?B 2/4 thyroid
disease
2/4 <( 2/4 C6< 2/4 CA
Personal and Social History:

1atient is a !ollege graduate and has been 0or7ing as a messenger
'or nine years. 1atient is a non/smo7er and non/al!oholi! be.erage drin7er.
1atient li.es 0ith 0i'e and 3 !hildren in a t0o/storey house that ha.e
bedrooms, a 7it!hen and li.ing room. -ouse is 0ell/.entilated, 0indo0 is
appro,imately , meters in a * , * meter 'loor si&e. @arbage is
!olle!ted e.eryday and 0ater is supplied by (aynilad.
1atient is a non/!o''ee drin7er and has no 'ood pre'eren!es.
Review of Systems:
General: 2/4 0eight gain 2/4 0eight loss 2/4 'atigue
2/4 'e.er 2/4 !hills
2/4 anore,ia
Skin: 2/4 rash 2/4 s!aling 2/4 bleeding 2/4 it!hing 2/4 !olor
!hange
2/4 sores 2/4 pale 2/4 moles 2/4 s!ars
yes: 2/4 !orre!ti.e lenses or glasses 2/4 it!hing 2/4 pain 2/4 diploplia
2/4 redness 2/4 dryness
ars: 2/4 hearing loss 2/4 .ertigo 2/4 pain 2/4 tinnitus 2/4 lesions
!ose: 2/4 !hange o' smell 2/4 bleeding 2/4 sinus pain 2/4 dryness
2/4 dis!harge 2/4 epista,is5rhinorrhea
Mo"th: 2/4 bleeding gums 2/4 ul!ers 2/4 soreness 2/4 pain 2/4dryness
2/4 !hange o' taste 2/4 tootha!hes
#reast: 2/4 lumps 2/4 pain 2/4 nipple dis!harge 2/4 dimpling 2/4 bleeding
Respiratory: 2/4 !ough 2/4 sputum 2/4 hemoptosis 2/4 dyspnea
2/4 !hest pain 2/4 0hee&ing
Heart: 2/4 easy 'atigue 2/4 !hest pain 2/4 orthopnea 2/4 palpitations
2/4 dyspnea 2/4 paro,ysmal no!turnal dyspnea
GI$: 2/4 nausea 2/4 dysphagia 2/4 hematemesis 2/4 .omiting
2/4 hemato!he&ia 2/4 abdominal pain 2/4 melena 2/4 diarrhea
%rinary: 2/4 dysuria 2/4 urgen!y 2/4 dribbling 2/4 in!ontinen!e
2/4 hematuria
Genitalia: 2/4 it!hiness 2/4 in'e!tions 2/4 bleeding 2/4 dyspareunia
2/4 lesions 2/4 dryness
ndocrine: 2/4 0eight !hange 2/4 polyuria 2/4 polydipsia 2/4 polyphagia
2/4 heat5!old intoleran!e 2/4 e,!essi.e s0eating
Hematolo&ic: 2/4 easy bruising 2/4 bleeding tenden!y 2/4 bleeding gums
2/4 epita,is
M"sc"loskeletal: 2/4 Aoint pain 2/4 limitation o' mo.ement 2/4 sti''ness 2/4
edema
!e"rolo&ical: 2/4 heada!he 2/4 numbness 2/4 impaired memory
2/4 spee!h disorder 2/4 !on.ulsions
Psychiatric: 2/4 hallu!inations 2/4 depression 2/4 sleep disturban!es
I'( Physical )amination
General S"rvey
?he patient is 0ell/nourished. -e is a0are, !oherent, a'ebrile, alert and
ambulatory. $7in !olor is normal bro0n, 0arm and moist to tou!hB s7in is
elasti! 0ith good turgor.
*ital Si&ns
#P + 14*51** mm -g le't arm sitting position
PR + +" beats per minute 0ith regular beats
RR + 19 breaths per minute
$emperat"re + 36." C C
#ody Mass Inde) D 6 7g5 1.6* m E D 4.1 7g5mE
H!$: pin7 palpebral !onAun!ti.a, ani!teri! s!lera, no nasoaural
dis!harge, no
lymphadenopathy, no tonsillopharyngeal
Chest and ,"n&s: symmetri!al !hest e,pansion, no retra!tions, e#ual ta!tile
'remitus,
!lear breath sounds
Cardiovasc"lar: adynami! pre!ordium, normal rate and regular rhythm, no
murmurs
-.domen: 'labby, normoa!ti.e bo0el sound, so't, non/tender
)tremities: grossly normal e,tremities, 'ull and e#ual pulses, no edema
!%R/,/GIC-, '-M
Cere.ral
1atient is alert, !oherent and !ooperati.eB oriented to time, pla!e and
persons, able to remember remote, re!ent and immediate memory, able to
!al!ulate, has good Audgment and has abstra!t thin7ing.
Cranial !erves
C! I:
1atientFs nostrils are patent and able to identi'y odor.
C! II:
1atient has good .isual a!uity 0ith both eyes tested simultaneously.
1atient has
normal .isual 'ield and !an read the prints 0ithin 1 in!hes. 6isual
'ields are inta!t
upon doing !on'rontation test.
C! II and III:
1upil si&e and shape are e#ual, rea!ti.e to dire!t and !onsensual light,
near
response.
C! III0 I*0 1 *I: G,tra/o!ular mus!le inta!t
C! *:
$ensory / able to sense light tou!h on the 'orehead, !hee7s and Aa0.
1atient 0as
able to distinguish bet0een sharp and dull point stimulus.
(otor / strong temporal and masseter mus!les.
C! * 1 *II:
8nta!t !orneal re'le,.
C! *II:
Fa!e is symmetri!al, no ti!s, able to raise eyebro0s, 0rin7le 'orehead,
'ro0n, smile
symmetri!ally. ?aste sensation is inta!t.
C! *III:
?here is no hearing loss, able to hear rubbing o' 'ingers.
C! I' 1 ':
2>4 @ag re'le,, u.ula is mid/line
C! 'I:
1atient 0as able to shrug5ele.ate shoulder against resistan!e. ?he head
0as resistant
0hen laterally rotated.
C! 'II:
?ongue in the midline, no atrophy, nor hypertrophy. 3o tongue
de.iation.
Cere.ellar F"nction
Absen!e o' intention tremors. Alternating supination and pronation,
point/to/point
mo.ements, and heel to sheen test 0ere normal.
Motor System
3o mus!ular atrophy, no tremors, no in.oluntary mo.ements.
3ormotoni!
mus!le strength.
Sensory
Can 'eel pinpri!7, light tou!h and .ibration.
-as good position sense and inta!t stereoagnosia and graphesthesia.
Deep $endon Refle)es: all normoa!ti.e D >
Di)2Hallpike $est: 2/4 nystagmus
*is"al -c"ity:
1in/-ole ?est:
;< ;$ ;< ;$
*5) *54* *53*
*54* /1
-ssessment: -ypertension $tage 1
Grror o' re'ra!tion
Plan:
H For -ypertensi.e 0or7/up: CBC and 9rinalysis
GC@, Chest I/ray 21A4
3a, J>, Ca, Cl, B93, Crea
For ?C, ?@, -<=, =<=
;lmersartan * mg5tab, 1 tablet ;<
Clonidine ") mg5tab, 1 tablet $= 'or
B1 K 14*59* mm -g
;rphenadrine Citrate 3) mg5tablet and
1ara!etamol 4** mg5tab # + hours 1R3 'or
pain
H <aily B1 monitoring
H ?herapeuti! =i'estyle Changes
H =o0 salt, lo0 'at diet
H ?o !ome ba!7 a'ter 3 days
-ypertension is a disease due mostly to problems in the blood .essels in 0hi!h
there is a 'un!tional and stru!tural !hanges in the .as!ulature. ?he !onse#uen!es o' su!h
stru!tural !hanges !an lead to a!!elerated atheros!lerosis, hyaline and hyperplasti!
arterios!lerosis.
?he magnitude o' the arterial pressure is dependent on t0o hemodynami!
'a!tors: !ardia! output and total peripheral resistan!e. ?otal peripheral resistan!e is
a!!ounted 'or by resistan!e in the arterioles, predominantly to lumen si&e
1
. ?he lumen
si&e is determined by the thi!7ness o' the arteriolar 0all 0hi!h is a''e!ted by hormonal or
neuronal in'luen!es that !ause the arterioles to either dilate or !onstri!t. ?he
.aso!onstri!ting 'a!tors are angiotensin 88, !athe!holamines, thrombo,ane, leu7otrines
and endothelins. 6asodilators are 7inins, prostaglandins and nitri! o,ide. ?hese mediators
.asodilate or !onstri!t blood .essels by atta!hing to spe!i'i! !ell re!eptors on the sur'a!e
o' smooth mus!les. =a!ti! a!id, hydrogen ions, and adenosine are also lo!al .asodilators.
Autoregulation, a pro!ess by 0hi!h in!reased blood 'lo0 to .essels lead to
1
$!hoen, Frederi!7. : Blood 6essels. 8n Robbins Pathologic Basis of Disease, )th ed. 1hiladelphia, LB
$aunders Co., 1994, p.4+) to 4+6.
.aso!onstri!tion, is an important property to resistan!e .essels. 8t is an adapti.e
me!hanism that prote!ts 'lo0 'rom hyperper'usion. =o!al le.els o' adenosine mediate
autoregulation and e.entually leads to in!reased !ardia! 0or7load, redu!tion in !ardia!
output, and !orre!tion o' hyper'usion. Arterial hypertension is !onsidered as a disease
dependent on 'a!tors that may alter the relationship bet0een blood .olume and total
arteriolar resistan!e.

?he 7idneys play an integral role in blood pressure regulation by three pro!esses.
?he 'irst deals 0ith the renin/angiotensin system. Renin produ!tion in the 7idney 'orms
angiotensin 88, 0hi!h alters blood pressure by in!reasing peripheral blood resistan!e and
blood .olume. Angiotensin 8 !auses .aso!onstri!tion through dire!t a!tion on the smooth
mus!le 0all 0hile angiotensin 88 !auses .aso!onstri!tion by stimulation o' aldosterone
se!retion in the distal tubule thus in!reasing re/absorption o' sodium and 0ater. ?he
se!ond me!hanism deals 0ith sodium homeostasis. $odium homeostasis is regulated by
the glomerular 'iltration rate 2@FR4 and @FR/independent natriureti! 'a!tors. Lhen
blood .olume is redu!ed, the @FR 'alls, thus leading to in!reased re/absorption o'
sodium by pro,imal tubules in an attempt to !onser.e sodium and e,pand blood .olume.
Atrial natriureti! 'a!tor 2A3F4 also a @FR dependent 'a!tor is a group o' peptides that is
se!reted by heart atria in response to .olume e,pansion. 8t inhibits sodium re/absorption
in the distal tubules and !auses .asodilation. ?he third me!hanism deals 0ith renal
.asodepressor substan!es. ?he 7idney produ!es a .ariety o' .asodepressor or
antihypertensi.e substan!es 0hi!h in!lude prostaglandins, a urinary 7alli7rein/7inin
system, platelet/a!ti.ating 'a!tor and nitri! o,ide.
Classi'i!ation o' hypertension is based on the M$e.enth Report o' the Joint

$!hoen, Frederi!7. : Blood 6essels. 8n Robbins Pathologic Basis of Disease, )th ed. 1hiladelphia, LB
$aunders Co., 1994, p.4+) to 4+6.
3ational Committee on 1re.ention and <ete!tion, G.aluation, and ?reatment o' -igh
Blood 1ressureM pro.ides a ne0 guideline 'or hypertension pre.ention and management.
?he 'ollo0ing are the reportFs 7ey messages:
8n persons older than )* years, systoli! blood pressure greater than 14* mm -g is
mu!h more important !ardio.as!ular disease 2C6<4 ris7 'a!tor than diastoli!
blood pressure
?he ris7 o' C6< beginning at 11)5") mm -g doubles 0ith ea!h in!rement o'
*51* mm -gB indi.iduals 0ho are normotensi.e at age )) ha.e a 9* per!ent
li'etime ris7 'or de.eloping hypertension.
8ndi.iduals 0ith systoli! blood pressure o' 1*/13* mm -g or a diastoli! pressure
o' +*/+9 mm -g should be !onsidered as prehypertensi.e and re#uire health
promoting li'estyle modi'i!ations to pre.ent C6<.
?hia&ide/type diureti! should be used in drug treatment 'or most patients 0ith
un!ompli!ated hypertension, either alone or !ombined 0ith drugs 'rom other
!lasses. Certain high/ris7 !onditions are !ompelling indi!ations 'or the initial use
o' other antihypertensi.e drug !lasses 2angiotensin !on.erting en&yme inhibitors,
angiotensin re!eptor blo!7ers, beta/blo!7ers, !al!ium/!hannel blo!7ers4.
(ost patients 0ith hypertension 0ill re#uire t0o or more antihypertensi.e
medi!ations to a!hie.e goal blood 2N14*59* mm -g or N13*5+* mm -g 'or
patients 0ith diabetes or !hroni! 7idney disease4.
8' blood pressure is O*51* mm -g abo.e goal blood pressure, !onsideration
should be gi.en to initiating therapy 0ith t0o agents, one o' 0hi!h usually should
be a thia&ide diureti!.
?he most e''e!ti.e therapy pres!ribed by the most !are'ul !lini!ian 0ill !ontrol
hypertension only i' patients are moti.ated. (oti.ation impro.es 0hen patients
ha.e positi.e e,perien!es 0ith, and trust in, the !lini!ian. Gmpathy builds trust
and is a potent moti.ator.
8n presenting these guidelines, the !ommittee re!ogni&es that the responsible
physi!ianFs Audgment remains paramount.
$a.le 3: Classification and Mana&ement of .lood press"re for ad"lts
#P
Classification
S#P
mm H&
D#P
mm H&
,ifestyle
Modification
4itho"t
Compellin&
Indication
5initial dr"&
therapy6
4ith
Compellin&
5initial dr"&
therapy6
!ormal N1* N+* en!ourage 3o
antihypertensi.e
drug indi!ated
<rug2s4 'or
!ompelling
indi!ations
Pre2HP! 1*/139 +* to +9 Pes 3o
antihypertensi.e
drug indi!ated
<rug2s4 'or
!ompelling
indi!ations
Sta&e 3
Hypertension
14*/1)9 9*/99 Pes ?hia&ide/type
diureti!s 'or
most. (ay
!onsider ACG8,
ARB, BB,
CCB, or
!ombination
<rug2s4 'or
!ompelling
indi!ations.
;ther
antihypertensi.e
drugs 2diureti!s,
ACG8, ARB,
BB, CCB4 as
needed
Sta&e 7
Hypertension
K 16* K 1** Pes ?0o/drug
!ombination 'or
most 2usually
thia&ide/type
diureti!, and
ACG8, or ARB,
or BB or CCB4
<rug2s4 'or
!ompelling
indi!ations.
;ther
antihypertensi.e
drugs 2diureti!s,
ACG8, ARB,
BB, CCB4 as
needed


?he a!!urate method o' B1 measurement 0ith a properly !alibrated and

.alidated instrument should be used. 1ersons should be seated #uietly 'or at least )
minutes in a !hair 2rather than on an e,am table4, 0ith 'eet on the 'loor, and arm
supported at heart le.el. (easurement o' B1 in the standing position is indi!ated
periodi!ally, espe!ially in those at ris7 'or postural hypotension. An appropriate/si&ed
!u'' 2!u'' bladder en!ir!ling at least +*Q o' the arm4 should be used to ensure a!!ura!y.
At least t0o measurements should be made. $B1 is the point at 0hi!h the 'irst o' t0o or
more sounds is heard 2phase 14 and <B1 is the point be'ore the disappearan!e o' sounds
2phase )4. Clini!ians should pro.ide to patients, .erbally and in 0riting, their spe!i'i! B1
numbers and B1 goals.
$a.le 7( Cardiovasc"lar risk factors
Ma8or Risk Factors
-ypertension
Cigarette smo7ing
;besity 2body mass inde, , 3* 7g5mE4
1hysi!al ina!ti.ity
<yslipidemia
<iabetes mellitus
(ir!oalbuminuria or estimated @FR N 6* m=5min
Age 2older than )) men, 6) 'or 0omen4
Family -istory o' premature !ardio.as!ular disease 2men under age )), 0omen under 6)4
$a.le 9( $ar&et /r&an Dama&e
Heart
=e't .entri!ular hypertrophy
Angina or prior myo!ardial in'ar!tion
1rior !oronary re.as!ulari&tion
-eart Failure
#rain
$tro7e or transient is!hemi! atta!7
Chronic :idney Disease
Peripheral -rterial Disease
Retinopathy
Routine laboratory tests re!ommend be'ore initiating therapy in!lude an
ele!tro!ardiogram, urinalysis, blood glu!ose and hemato!rit, serum potassium, !reatinine
2or the !orresponding estimated glomerular 'iltration rate R@FRS4, and !al!iumB and lipid
pro'ile, a'ter a 9/1 hour 'ast, that in!lude high density lipoprotein !holesterol, lo0
density lipoprotein !holesterol, and trigly!erides. ;ption tests in!lude measurement o'
urinary albumin e,!retion or albumin5!reatinine. (ore e,tensi.e testing 'or identi'iable
!auses is not indi!ated generally unless B1 !ontrol is not a!hie.ed.
$a.le ;( ,ifestyle Modifications to mana&e hypertension
Modification Recommendation -ppro)imate S#P
Red"ction 5ran&e6
Leight redu!tion (aintain normal body
0eight 2body mass inde,
1+.) to 4.9 7g5mE4
)/* mm -g51* 7g 0eight
loss
Adopt <A$- 2dietary
approa!h to stop
hypertension4 eating plan
Consume a diet ri!h in
'ruits, .egetables, lo0 'at
dairy produ!ts 0ith a
redu!ed !ontent o' saturated
and total 'at
+/14 mm -g
<ietary sodium restri!tion Redu!e dietary sodium
inta7e to no more than 1**
mmol per day 2.4 g sodium
or 6 g sodium !hloride4
/+ mm -g
1hysi!al a!ti.ity Gngage in regular aerobi!
e,er!ise su!h as bris7
0al7ing 2at least 3* minutes
per day, most days o' the
0ee74
4/9 mm -g
(oderation o' al!ohol
!onsumption
=imit al!ohol !onsumption
to no more than drin7s 21
o&. or 3* m= ethanolB eg 4
o& beer, 1* o& 0ine, or 3 o&
+*/proo' 0his7ey4 per day
in most men and to no more
than 1 drin7 per day in
0omen and lighter 0eight
person
/4 mm -g