CASE

A 47 year-old man presents to your office for a follow-up visit. He was seen 3 weeks ago for
an upper respiratory infection and noted incidentally to have a blood pressure of 164/98 mm
Hg . he vaguely remembered being told in the past that his blood pressure was borderline .
he feels fine , has no complaints , and his review of systems is entirely negative. He does not
smoke cigarettes, drinks a couple of beers on the weekends, and does not exercise
regularly. He has a sedentary job. His father died of a stroke at the age of 69 years. His
mother is alive and in good health at the age of 72 years. He has two siblings and is not aware
of any chronic medical issues that they have. In the office today, his blood pressure is 156/96
mmHg in his left arm and 152/98 mmHg in the right arm. He is afebrile , his pulse is 78
bpm , respiratory rate 14 breaths per minute, he is 70 in tall, and weighs 210 Ib . a general
physical examination is normal.

KEYWORD
. A 47 year-old man
. Upper respiratory infection
. Blood pressure of 164/98 mm Hg
. Blood pressure was borderline
. does not exercise regularly
. His father died of a stroke
. 156/96 mmHg in his left arm (today)
. 152/98 mmHg in the right arm (today)

PROBLEM
Mr. A has high blood pressure

TAKING NOTE 1
Surename : A
Age : 47 years
Sex : man
Occupation : Sedentary job
Present complaint : follow up visit

O/E
General condition : 70 in tall, 210 LB
ENT : NAD
RS :

RR : 14 breaths/minute

CVS : P : 78 bpm

blood pressure : 156/96 mmHg in his left arm

152/98 mmHg in the right arm

HS: normal

GUS : CNS : Immediate past history : he was seen 3 weeks ago for an upper respiratory infection and noted
incidentally to have a blood pressure of 164 / 98 mmHg . his father died of a stroke at the age
of 69 years
Diagnosis : hypertension
Management : kaptopril, tiazid, beta blocker, diuretics

Taking note 2
System
ENT
RS
CVS

Complaint

No complaint

GIS
GUS
CNS
Psychiatric

Order
156/96 mmHg
(Left Arm)
152/98 mmHg
(Right Arm)

Conversation
D

: Good Morning, My name is dr.Octopus

: Morning dok

: What is your name ?

: My name is Mr.A

: How old are you ?

: 47 years old

: what is your address ?

: Jl.Pramuka Kemiling, Bandar Lampung

: What is you occupation ?

: i have sedentary job

: what brought you along today ?

: I want to follow up my body

: what do you feel about your body ?

P
: 3 weeks ago . I was seen for upper respiration and noted incidentaly to have a blood
pressure of 164/98 mmHg
D

: and then ?

: i remember in the past that my blood preasurre was border line

: How about habituation ? are you smoker ?

: No, i am not

: Do you like drink an alkohol ?

: I drinks a couple of beers on the weekend

: Do you have any exercise regularly ?

: No, I dont

: In your family, do they have same problem like you ? can you tell me ?

P
: My Father have died because stroke at the age of 69 years . My mother and my
siblings is normal
D

: Oke. Thank you . Its time to fisic excamination .

: Oke lets go dok

D
:The result of your follow up is something wrong with your blood presurre its higher
than normal blood pressure.

HYPERTENSION
DEFINITION
Blood pressure is the force of blood pushing up against the blood vessel walls. The higher the
pressure the harder the heart has to pump.
The normal level for blood pressure is below 120/80, where 120 represents the systolic
measurement (peak pressure in the arteries) and 80 represents the diastolic measurement
(minimum pressure in the arteries). Blood pressure between 120/80 and 139/89 is called
prehypertension (to denote increased risk of hypertension), and a blood pressure of 140/90 or
above is considered hypertension.
Hypertension, also referred to as high blood pressure, is a condition in which the arteries have
persistently elevated blood pressure. Every time the human heart beats, it pumps blood to the
whole body through the arteries.

EPIDEMIOLOGY
Some 70 million adults in the United States are affected by hypertension. The condition also
affects about two million teens and children. According to a report issued by the Centers for
Disease Control and Prevention (CDC) in September 2012, over half all Americans with
hypertension do not have their high blood pressure under control.

CAUSES
Though the exact causes of hypertension are usually unknown, there are several factors that
have been highly associated with the condition. These include:

Smoking
Obesity or being overweight

Being obese/overweight as a child - a research team at the Indiana University School

of Medicine found that obese/overweight children are much more likely to suffer from
hypertension during adulthood.

Diabetes

Sedentary lifestyle

Lack of physical activity

High levels of salt intake (sodium sensitivity). According to the American Heart
Association (AHA), sodium consumption should be limited to 1,500 milligrams per
day, and that includes everybody, even healthy people without high blood pressure,
diabetes or cardiovascular diseases. AHA's chief executive officer, Nancy Brown said

"Our recommendation is simple in the sense that it applies to the entire U.S
population, not just at-risk groups. Americans of all ages, regardless of individual risk
Though the exact causes of hypertension are usually unknown, there are several
factors that have been highly associated with the condition factors, can improve the
heart health and reduce their risk of cardiovascular disease by restricting their daily
consumption of sodium to less that 1,500 milligrams." The recommendation was
published in the journal Circulation (November 5th, 2012 issue)

Insufficient calcium, potassium, and magnesium consumption

Vitamin D deficiency

High levels of alcohol consumption

Stress

Aging

Medicines such as birth control pills

Genetics and a family history of hypertension - In May 2011, scientists from the
University of Leicester, England, reported in the journal Hypertension that some
genes in the kidneys may contribute to hypertension.

Chronic kidney disease

Adrenal and thyroid problems or tumors

RISK FACTOR
High blood pressure is more common in older people. At age 45, more men have
hypertension than women. By age 65, this is reversed and more women are affected. People
with diabetes have a greater risk of hypertension than those without diabetes, and having a
close family member with high blood pressure also increases your risk of developing it.
About 60% of all people with diabetes also have hypertension.
Hypertension and Race
African-Americans are at greater risk of developing hypertension than people of other races.
Some studies suggest that African-Americans may be more sensitive to salt than other races.
For those who are genetically prone to salt sensitivity, a small amount like a half-teaspoon of
salt can raise blood pressure by 5 mm Hg. Dietary factors and being overweight can also raise
blood pressure.
Hypertension and Sodium
Sodium, a chemical found in salt, raises blood pressure by promoting the retention of fluid by
the body. This increases the workload on the heart. The American Heart Association
recommends an upper daily limit for sodium consumption of 1,500 mg. Checking food labels
and menus can help you calculate how much sodium you are consuming. Processed foods are

particularly high in sodium and make up about 75% of our sodium intake. Among these,
lunch meats and canned soups have some of the highest levels of dietary sodium.
Hypertension and Stress
Stress leads to temporary elevations of blood pressure, but there is no proof that stress causes
ongoing high blood pressure. Stress may have an indirect effect on blood pressure since it can
influence other risk factors for heart disease. People who are under stress tend to engage more
in unhealthy habits like poor nutrition, alcohol use, and smoking, all of which can play a role
in the development of high blood pressure and heart disease.
Hypertension and Weight
Being overweight increases the risk of getting hypertension and increases the workload
required of your heart. Diets designed to control blood pressure are often designed to reduce
calories as well. Most of these diets require decreasing consumption of fatty food and sugars
while increasing your intake of lean protein, fiber, fruits, and vegetables. A weight loss of just
10 pounds can make a difference in your blood pressure.
Hypertension and Alcohol
Drinking too much alcohol is a risk factor for high blood pressure. The American Heart
Association guidelines recommend the consumption of no more than two alcoholic drinks per
day for men and no more than one drink a day for women. One drink is defined as one 12ounce beer, 4 ounces of wine, 1.5 ounces of 80-proof spirits, or 1 ounce of 100-proof spirits.
Hypertension and Caffeine
Caffeine can bring on the jitters, but there is no evidence that it can cause long-term
hypertension. However, especially for those not accustomed to caffeine, a caffeinated
beverage might bring on a temporary rise in blood pressure.
Hypertension and Pregnancy
Gestational hypertension is high blood pressure that develops in pregnancy. If not properly
managed, it may develop into preeclampsia. Preeclampsia is elevated blood pressure and the
leakage of protein into the urine by the kidneys. Preeclampsia can be dangerous to both
mother and baby. After the baby is born, high blood pressure of pregnancy usually returns to
normal levels.
Hypertension and Medicine
Certain medications contain ingredients that can elevate blood pressure. Cold and flu
medications that contain decongestants are one example of drugs that raise blood pressure.
Other kinds of medicines that can raise blood pressure are steroids, diet pills, birth control
pills, NSAID pain relief medications, and some antidepressants. Talk to your doctor about the
medications or supplements you may be taking that might affect your blood pressure.

'White Coat' Hypertension

Sometimes people have a higher blood pressure reading when they are in the doctors office.
This may be due to anxiety or nervousness. For the most accurate readings, take your blood
pressure at home at different times and share these measurements with your doctor. To
determine if your readings are accurate, bring your home blood pressure monitor to the
doctors office so that the device and your technique can be evaluated.
Hypertension and Children
Although it's most common in older adults, hypertension can also affect children. The normal
blood pressure for a child is dependent upon the childs age, gender, and height. Your doctor
can tell if your childs blood pressure is abnormal. Children are at higher risk for
hypertension if they are overweight, are African-American, or if they have a family history of
the condition.

CLASSIFICATION
Hypertension may be classified as essential or secondary. Essential hypertension is the term
for high blood pressure with unknown cause. It accounts for about 95% of cases. Secondary
hypertension is the term for high blood pressure with a known direct cause, such as kidney
disease, tumors, or birth control pills.

SYMPTOMS
There is no guarantee that a person with hypertension will present any symptoms of the
condition. About 33% of people actually do not know that they have high blood pressure, and
this ignorance can last for years. For this reason, it is advisable to undergo periodic blood
pressure screenings even when no symptoms are present.
Extremely high blood pressure may lead to some symptoms, however, and these include:
Severe headaches
Fatigue or confusion

Dizziness

Nausea

Problems with vision

Chest pains

Breathing problems

Irregular heartbeat

Blood in the urine

DIAGNOSED
Hypertension may be diagnosed by a health professional who measures blood pressure with a
device called a sphygmomanometer - the device with the arm cuff, dial, pump, and valve. The
systolic and diastolic numbers will be recorded and compared to a chart of values. If the
pressure is greater than 140/90, you will be considered to have hypertension.
A high blood pressure measurement, however, may be spurious or the result of stress at the
time of the exam. In order to perform a more thorough diagnosis, physicians usually conduct
a physical exam and ask for the medical history of you and your family. Doctors will need to
know if you have any of the risk factors for hypertension, such as smoking, high cholesterol,
or diabetes.
If hypertension seems reasonable, tests such as electrocardiograms (EKG) and
echocardiograms will be used in order to measure electrical activity of the heart and to assess
the physical structure of the heart. Additional blood tests will also be required to identify
possible causes of secondary hypertension and to measure renal function, electrolyte levels,
sugar levels, and cholesterol levels.

THREATMENT
The main goal of treatment for hypertension is to lower blood pressure to less than 140/90 or even lower in some groups such as people with diabetes, and people with chronic kidney
diseases. Treating hypertension is important for reducing the risk of stroke, heart attack, and
heart failure.
High blood pressure may be treated medically, by changing lifestyle factors, or a combination
of the two. Important lifestyle changes include losing weight, quitting smoking, eating a
healthful diet, reducing sodium intake, exercising regularly, and limiting alcohol
consumption.
Medical options to treat hypertension include several classes of drugs. ACE inhibitors, ARB
drugs, beta-blockers, diuretics, *calcium channel blockers, alpha-blockers, and peripheral
vasodilators are the primary drugs used in treatment. These medications may be used alone or
in combination, and some are only used in combination. In addition, some of these drugs are
preferred to others depending on the characteristics of the patient (diabetic, pregnant, etc.).
*Calcium-channel blockers and cancer risk - postmenopausal females who took calciumchannel blockers for 10 years were found to be 2.5 times more likely to develop breast cancer
compared to women who never took them or those on other hypertension medications.
If blood pressure is successfully lowered, it is wise to have frequent checkups and to take
preventive measures to avoid a relapse of hypertension.

Treatment: The DASH Diet

Dietary changes can help control blood pressure. One diet designed to promote lower blood
pressure is known as the DASH diet. This stands for Dietary Approaches to Stop
Hypertension. The DASH diet recommends eating more vegetables, fruits, whole grains, lowfat dairy products, poultry, nuts, and fish. Red meat, saturated fats, and sweets should be
avoided. It can also help to reduce your intake of sodium.
Treatment: Exercise
Exercise is another lifestyle factor that can lower blood pressure. Its recommended that
adults get about 150 minutes per week of moderate exercise. This can include activities like
walking, bicycling, gardening, or other aerobic exercise. Muscle-strengthening activities are
recommended at least twice a week.
Treatment: Diuretics
If diet and exercise are not sufficient to lower blood pressure, the first medications
recommended are often diuretics or so-called "water pills." These reduce sodium and fluid
levels in the body to lower blood pressure. Taking diuretics means you will urinate more
frequently. Sometimes, diuretics deplete potassium levels as well, which can lead to muscle
weakness, leg cramps, and tiredness. Other side effects of diuretics can include elevated
blood sugars in people with diabetes. Less commonly, erectile dysfunction can occur.
Treatment: Beta-blockers
Beta-blockers are another drug used to treat hypertension. They work by slowing the heart
rate and thereby decreasing the workload of the heart. They can be used to treat other
conditions as well, including abnormal heart rate (arrhythmia). Side effects of beta-blockers
can include dizziness, insomnia, fatigue, cold feet and hands, and erectile dysfunction.
Treatment: ACE Inhibitors
ACE (angiotensin converting enzyme) inhibitors are another class of antihypertensive drugs.
They reduce the bodys levels of angiotensin II, a substance that narrows blood vessels. This
means that arteries are more open (dilated) and the blood pressure is lower. Side effects of
ACE inhibitors can include skin rash, dry cough, dizziness, and elevated potassium levels.
Women taking ACE inhibitors should not become pregnant.
Treatment: ARBs
Instead of lowering angiotensin II levels, a related class of drugs called ARBs or angiotensin
receptor blockers prevents the actions of angiotensin II on the arteries. This means the arteries
stay more open and blood pressure is lowered. ARBs can take a few weeks to work. Side
effects can include dizziness, muscle cramps, insomnia, and elevated potassium levels. As
with ACE inhibitors, women taking ARBs should not become pregnant.

Treatment: Calcium Channel Blockers

Calcium channel blockers are drugs that reduce the movement of calcium into cells of the
heart and vessels. This reduces the strength of heart contractions and relaxes the arteries,
allowing them to remain more open, lowering blood pressure. Side effects of calcium channel
blockers can include heart palpitations, dizziness, swollen ankles, and constipation. They
should be taken with food or milk. Because of potential interactions, those taking calcium
channel blockers should avoid alcohol and grapefruit juice.
Treatment: Other Medications
There are even more medication types that can lower blood pressure. Some of these are alpha
blockers, vasodilators, and central alpha agonists. Your doctor may prescribe these
medications if other medications have been ineffective or if you have another condition along
with hypertension. Side effects can include fast pulse, palpitations, diarrhea, or headaches.
Treatment: Complementary Therapies
It has been shown that meditation and other relaxation techniques can help lower blood
pressure. Yoga, tai chi, and breathing exercises can also help reduce blood pressure. Its best
when these are combined with changes in diet and exercise. Tell your doctor if you are taking
any herbal remedies, since some of these preparations can actually raise blood pressure or
interact with your blood pressure medications.

How can hypertension be prevented?

Hypertension can best be prevented by adjusting your lifestyle so that proper diet and
exercise are key components. It is important to maintain a healthy weight, reduce salt intake,
reduce alcohol intake, and reduce stress.
In order to prevent damage to critical organs and conditions such as stroke, heart attack, and
kidney failure that may be caused by high blood pressure, it is important to screen, diagnose,
treat, and control hyper tension in its earliest stages. This can also be accomplished by
increasing public awareness and increasing the frequency of screenings for the condition.

CONCLUSION
Hypertension, also referred to as high blood pressure. Blood pressure between 120/80 and
139/89 is called prehypertension (to denote increased risk of hypertension), and a blood
pressure of 140/90 or above is considered hypertension. High blood pressure is more
common in older people. At age 45, more men have hypertension than women.
Though the exact causes of hypertension are usually unknown, there are several factors that
have been highly associated with the condition
Hypertension may be classified as essential or secondary . There is no guarantee that a person
with hypertension will present any symptoms of the condition. About 33% of people actually
do not know that they have high blood pressure, and this ignorance can last for years.
High blood pressure may be treated medically, by changing lifestyle factors
Hypertension can best be prevented by adjusting your lifestyle so that proper diet and
exercise are key components. It is important to maintain a healthy weight, reduce salt intake,
reduce alcohol intake, and reduce

REFERENCE
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