Download HTN Soap note with graphs

FINAL DRAFT-HTN 4/1/08
SUBJECTIVE
Patient presents for evaluation of confirmed hypertension
CLASSIFICATION OF BLOOD PRESSURE (BP)*
CATEGORY
SBP mmHg
Normal
< 120
DBP mmHg
and
< 80
Prehypertension
120 – 139
or
80 - 89
Hypertension, Stage1
140 – 159
or
90 – 99
Hypertension, Stage 2
> 160
or
> 100
* See Blood Pressure Measurement Techniques (reverse side)
Key: SBP = systolic blood pressure
DBP = diastolic blood pressure
*** For those with high pressures (systolic greater than 180 mm Hg or diastolic greater than 110
mm Hg) evaluate and treat immediately or within one week, depending on clinical situation and
complications.
Confirm Elevated Blood Pressure:
Confirmation is based on the initial visit, plus two follow up visits with at least two blood
pressure readings at each visit.
At least once a BP must be checked in both arms. At least once the BP must be taken in
the upper arm above the antecubital space.
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Medications and Compliance Reviewed
Medications that contribute to elevated BP
-NSAIDS
-decongestants
-diet aids
-herbals
Past history reviewed/Problem list
Pertinent conditions (CAD, angina, previous MI, DM, CHF, PVD, prior hx HTN,
previous HTN rx, lipid disorders (including metabolic syndrome), LVH,
Retinopathy, Renal disease (GFR<60 and microalbuminuria)
Lifestyle factors
Smoking, high sodium intake, high fat diet, physical inactivity, excessive alcohol,
overweight (BMI>30)
Family history
Cardiovascular
Dyslipidemia
Diabetes
Family history of premature cardiovascular disease (men younger than 55 or
women younger than 65).
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ROS
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Constitutional (wt gain or loss), fatigue
Visual (blurred vision, other)
Neurological (headache, dizziness, weakness, loss of feeling, other)
Respiratory (dyspnea at rest or activity, snoring, apneic spells)
Cardiac (Chest pain with or without exertion, palpitations, irregular pulse,
orthopnea, claudication, edema)
 Neuropsych (depression, insomnia, psychosocial stress, anxiety)
PHYSICAL EXAM
 Vitals
 Waist circumference
 General (grooming, orientation, distress, obesity, other)
 Head
 Fundoscopic (hemorrhages, exudates, AV crossing changes, disc normal or
edematous, arteriolar narrowing general or focal, cataracts, eye doctor visit)
 Neck (JVD, thyromegaly, carotid bruits, other)
 Lungs (auscultation, percussion, respiratory effort, rales, wheezing, rhonchi, other)
 Heart (rhythm, murmurs, PMI, gallop, click, other)
 Abdomen (soft, tenderness, organomegaly, abnormal pulsation, bruits, enlarged
kidneys, mass, other)
 Neurological (localized weakness, facial droop, gait)
 Extremities ( edema, pulses, symmetry, radial-femoral delay)
 Psych (orientation, mood, affect)
LAB
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FBS
HCT
Na
K
Creatinine (GFR)
Ca
Lipids
12 lead EKG
Additional tests may be ordered at the discretion of the provider based on clinical findings. These
may include, but are not limited to, CBC, CXR, uric acid, and urine microalbumin.
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ASSESSMENT
Primary hypertension without target organ disease or with target organ disease (LVH, CAD,
CABG, CHF, PVD, angina, renal disease, retinopathy, stroke, TIA, dementia)
ASSESS FOR IDENTIFIABLE CAUSES OF HYPERTENSION
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Sleep apnea
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Cushing’s syndrome or steroid therapy
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Drug induced/related
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Pheochromocytoma
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Chronic kidney disease
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Coarctation of aorta
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Primary aldosteronism
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Thyroid/parathyroid disease
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Renovascular disease
Risk Factors for Major Cardiovascular Disease:
 Hypertension
 Age (older than 55 for men, 65 for women)
 Diabetes mellitus
 Elevated LDL cholesterol
 Low HDL cholesterol (men <40 mg/dL, women <50mg/dL)
 Estimated GFR less than 60 mL/min
 Microalbuminuria
 Family history of premature cardiovascular disease (men younger than 55 or
women younger than 65)
 Obesity (body mass index greater than or equal to 30 kg/m2, waist
circumference greater than 40 inches for men and greater than 35 inches for women)
 Physical inactivity
 Tobacco usage, particularly cigarettes
Consider a Diagnosis of Secondary HTN:
 Patients with an abrupt onset of symptomatic HTN
 Stage 2 hypertension
 Hypertensive crisis
 Sudden loss of BP control after many years of stability on drug therapy
 Drug resistant HTN
 Individuals with no family history of HTN
 Acute increase in plasma creatinine that is unexplained or after an initial treatment
with an ACE or an ARB
 Lateralizing abdominal bruit
 Recurrent flash pulmonary edema
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Secondary Etiology
Clinical Scenario
Tests
Renal artery stenosis
FMD – young
females
Older patients with
vascular disease
Duplex Doppler US
or
MRA or
CT angiogram
Primary renal disease
Abnormal GFR
GFR
UA
Pheochromocytoma
Headache (90%),
palpitations,
sweating/pallor,
paroxysm of HTN
or persistent HTN
(50/50)
Hypokalemia,
adrenal
incidentaloma
24 urine
fractionated
metanepharines or
Plasma fractionated
metanepharines
Primary aldosteronism
Cushing’s Disease
“moon”facies,
central obesity,
stria, ecchymosis
Obstructive Sleep Apnea
Snoring +/- apneic
spells, daytime
somnelence
Absent or lagging
LE pulses
Both hypo and
hyper
Hypercalcemia –
stones, groans, and
psychic overtones
Coarctation of the Aorta
Thyroid disorder
Hyperparathyroidism
Plasma aldosterone
concentration
(PAC) to plasma
renin activity (PRA)
= PAC/PRA
1mg Overnight
Dexamethasone
Suppression Test
24 hour urine
cortisol
Overnight Sleep
Study
Comments
All are options and
debated. MRA most
often used at Theda for
screening. If pt has RI
Nephrogenic Systemic
Fibrosis, although rare,
now a real issue as it is
life threatening.
Contrast induced
nephropathy also issue
with CT angio.
Renal US can show
asymmetry and
Polycystic Kidney
Disease.
Options are debated.
Different sources will
sight different cutoffs to
change sensitivity and
specificity. In general,
<20 normal
Options are debated.
CT angiogram
TSH
TSH sufficient for
screening test.
PTH
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Calculated 10 year CHD risk
Goal BP
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< 140/90
Goal BP for those pts with diabetes, CKD, and heart failure: <130/80
Goal blood pressures measured out of the office setting should be:
 <135/85 (no comorbidities)
 <125/75 ( those with comorbidities) Review this with the patient.
Goal blood pressures for those patients with chronic kidney disease:
 <130/80
 <120/75 if urinary protein excretion > 1-2g/day
Consider 24 hour ambulatory blood pressure monitoring (ABPM) in the assessment of white coat
or office effect patients who lack evidence of target organ damage, and who have normal out-ofoffice BP readings. Other clinical situations in which ABPM may be helpful include the
assessment of drug resistance, hypotensive symptoms, episodic hypertension and suspected
autonomic dysfunction.
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PLAN
Lifestyle modifications should be:
 The cornerstone of the initial therapy for hypertension
 Reviewed and re-emphasized at least annually
Lifestyle Modifications to Prevent and Manage Hypertension
Modification
Recommendation
Approximate SBP
reduction
(range)
Weight reduction
Adopt DASH** eating plan
Dietary sodium reduction
Physical activity
Moderation of alcohol
consumption
Maintain normal body weight
(body mass index 18.5-24.9
kg/m2).
Consume a diet rich in fruits,
vegetables and low-fat dairy
products, with a reduced
content of saturated and total
fat.
Reduce dietary sodium intake
to no more than 100 mmol per
day (2.4 g sodium or 6 g
sodium chloride).
Engage in regular aerobic
physical activity such as brisk
walking (at least 30-45
minutes per day, most days of
the week).
Limit consumption to no more
than two drinks (e.g., 24 oz.
beer, 10 oz. wine, or 3 oz. 80
proof whiskey) per day in
most men and to no more than
one drink per day in women
and lighter-weight persons.
5-20 mm Hg/10 kg
8-14 mm Hg
2-8 mm Hg
4-9 mm Hg
2-4 mm Hg
**DASH indicates Dietary Approaches to Stop Hypertension.
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
Medications
COMPELLING INDICATIONS FOR INDIVIDUAL DRUG CLASSES
COMPELLING INDICATION
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Heart failure
INITIAL THERAPY OPTIONS
THIAZ, BB, ACEI, ARB, ALDO ANT
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Post myocardial infarction
BB, ACEI, ALDO ANT
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High CVD risk
THIAZ, BB, ACEI, CCB
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Diabetes
THIAZ, BB, ACEI, ARB, CCB
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Chronic kidney disease
ACEI, ARB
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Recurrent stroke prevention
THIAZ, ACEI
Key: THIAZ = thiazide diuretic, ACEI = angiotensin converting enzyme inhibitor, ARB = angiotensin receptor
blocker, BB = beta blocker, CCB = calcium channel blocker, ALDO ANT = aldosterone antagonist
Primary HTN Medications:
 A Thiazide type diuretic should be considered as initial therapy with uncomplicated
HTN.
 In patients for whom diuretics are contraindicated or poorly tolerated, use of a betablocker, ACE inhibitor, ARB or calcium antagonist is appropriate.
 Outcome data does not support B blockers for first line therapy for patients >60 years
of age.
 In order to decrease cost, consider three strategies: split tablet dosing, 3 month supply
by mail order and generic medications.
HTN with Diabetes:
 Regimen should include either an ACE inhibitor or an ARB. If one class is not
tolerated the other should be substituted.
 If needed to achieve BP targets:
GFR  50ml/min- a thiazide diuretic should be added
GFR < 50ml/min- a loop diuretic should be added
 Multiple drug therapy (two or more agents at maximal doses) is generally required to
achieve blood pressure targets.
FOLLOW UP
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Once a hypertensive drug therapy is initiated, most patients should return for follow
up and medication adjustments at least monthly until BP goal is reached.
Option if not at goal:
-Increase dose of initial drug.
-Substitute agent from another class
-Add a second drug from another class
BP at goal:
-Follow up office visit in 3-6 months
-Follow up visits to assess for target organ disease, new risk factors, comorbidities
and need for lab tests.
-Serum potassium and creatinine should be monitored at least annually. Additional
labs as indicated with change in condition or medication regimen.
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PATIENT EDUCATION
Website
Title/Description
Organization
http://www.americanheart.org
Web site with excellent
resources for patient education
and general heart health
resources. Understanding and
Controlling Your High Blood
Pressure and Exercise and Your
Heart.
Web site with excellent
resources for patient education.
Includes an online catalogue of
materials.
-Facts about Heart Disease and
Women: Preventing and
Controlling High Blood
Pressure (brochure #97-3655)
-Facts about Lowering Blood
Pressure (brochure #5232)
-Facts about the DASH Diet
(booklet #03-4082)
-Your Guide to Lowering Blood
Pressure (booklet #03-5232)
Web site with excellent
resources for patient education
resources, particularly using
search terms “hypertension,”
“blood pressure” and “home
monitoring.”
American Heart Association
(AHA)
http://www.nhlbi.nih.gov
http://www.mayoclinic.com
http://www.webmd.com
National Heart, Lung &
Blood Institute (NHLBI)
Mayo Health Oasis
Comprehensive health
resources for consumers,
physicians, nurses, and
educators. Includes news, chat
forums, health quizzes and
consumer product updates.
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REFERENCES
Institute for Clinical Systems Improvement Health Care Guideline, Hypertension Diagnosis and
Treatment, Eleventh Edition /October 2006. www.icsi.org
JNC 7, The Seventh Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure, U.S. Department Of Health And Human
Services, May 2003. www.nhlbi.nih.gov
Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection,
Evaluation, and Treatment of High Blood Cholesterol in Adults, Adult Treatment Panel III,
September 2002. www.nhlbi.nih.gov
Institute for Clinical Systems Improvement Health Care Management of Type 2 Diabetes
Mellitus, Eleventh Edition/ November 2006. www.icsi.org
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