Muhammad Hafizuddin Bin Ahmad Razid

121303150
Klinik Kesihatan Peringgit

Patient Details

Name : Madam Syamsida

Age : 49 years

Gender : Female

Race : Malay

Occupation : Housewife

Address : Batu Berendam

Date of Examination : 5/12/2017

Chief Complaint

Follow-up appointment for hypertension.

History of Presenting Illness

Patient was diagnosed with hypertension 2 years ago after she went to private clinic due to
headache and neck pain. The blood pressure at the time of diagnosis was 158/110 mmHg
and she was prescribed anti-hypertensive medication. She took the medication regularly. She
also diagnosed with hyperlipidemia and currently on medication which she took together with
the anti-hypertensive regularly. Patient did not complaint from blurring of vision, lethargy or
swelling of the leg. The blood pressure taken this morning is 135/84 mmHg.

Past History

No significant medical (DM, IHD, renal disease, BA) and surgical history.

Menstrual History

She attained menarche at the age of 14 years old. The cycle was regular. No menorrhagia or
dysmenorrhea.
 Muhammad Hafizuddin Bin Ahmad Razid
121303150
Klinik Kesihatan Peringgit

Family History

Both of her parents has passed away due to old age. Her mother has hypertension. She is the
second child out of 3 siblings. No other illness runs in the family.

Personal History

She is a non-alcoholic, non-smoker, not taking any illicit drugs. No known allergy to food or
medication. Normal bowel and bladder habit.

Socioeconomic History

She lives with her husband and 3 children in a housing area with good water and electrical
supply. The monthly income mainly given by her children and it is adequate.

General Examination

Patient is alert, cooperative and sitting comfortably on the chair. She is moderately built and
moderately nourished.

Vital signs

Temperature : 37.2C

Blood pressure : 135/84 mmHg

Pulse rate : 65 bpm, regular rhythm, normal volume and character

Respiratory rate : 19 breath/min

Hand examination : No clubbing, pallor or cyanosis.

Eyes examination : No pallor on conjunctiva, no icterus on sclera.

Nose : No deviated nasal septum, no nasal discharge

Mouth : Oral hygiene is good. Throat is not injected and the tongue is moist.
 Muhammad Hafizuddin Bin Ahmad Razid
121303150
Klinik Kesihatan Peringgit

Neck : No swelling seen on the neck.

Legs: No pedal edema.

Systemic Examination

Respiratory : Lung is clear with vesicular breath sound, no adventitious sound.

Cardiovascular : S1 and S2 are heard, no murmur.

Investigations

1) Full blood count, blood sugar level

2) Renal profile
3) Cholesterol level : 5.4 mmol/L
4) ECG

Diagnosis

Controlled hypertension

Management

1) Anti-hypertensive drugs : Amlodipine 10 mg OD

2) Drug for hyperlipidemia : Simvastatin 40 mg OD
 Muhammad Hafizuddin Bin Ahmad Razid
121303150
Klinik Kesihatan Peringgit

Discussion

Hypertension is one of the most common chronic diseases in the human population,
affecting more than 1 billion people worldwide. As blood flows through arteries it pushes
against the inside of the artery walls. The force against the walls of arteries forms blood
pressure. When the heart beats to push blood out into the arteries, blood pressure is highest
and called systolic pressure. When the heart relaxes to fill with blood again, the pressure is at
its lowest point and called diastolic pressure. Hypertension (high blood pressure) is defined
as a repeatedly elevated blood pressure reaching or exceeding 140 over 90 mmHg (a systolic
pressure 140 with a diastolic pressure 90) for adult.

Usually, hypertension patients have no special symptoms but the hypertension

complications are the main causes of death including heart disease, stroke, kidney damage
and loss of vision. Although the causes and mechanisms of hypertension cannot be clearly
determined in the majority of individuals with hypertension, there are some risk factors are
obviously related hypertension. Therefore, screening for hypertension is very important in
primary health care. Efforts must be made to reach the target blood pressure. For patients <80
years old, the target systolic blood pressure should be <140 mmHg and diastolic blood
pressure <90 mmHg. For patients above 80 years old, aim for a target of <150/90 mmHg.

Patient should be seated for at least 5 minutes, without smoking, meal, caffeine intake
or physical exercise for at least 30 minutes. The position must be seated, with back and arms
supported and in a quiet room. Legs must be uncrossed. The correct cuff must be used and
should be placed at heart level.

A detailed history and physical examination is essential for identifying risk factors and
stratifying patients to target those who need more aggressive therapy to achieve goal BP. The
history should include details of dietary salt intake and should explore lifestyle patterns and
social and psychosocial stressors that could potentially affect BP levels. Ophthalmologic
assessment and funduscopic examination are simple techniques to identify the severity of
disease and target organ damage by grading retinal changes

The minimum investigations aim to screen the presence of secondary causes of

hypertension, determine the presence of cardiovascular risk factors, target organ damage
(TOD) and target organ complication (TOC). They include urinalysis, renal function test, blood
glucose, lipid profile and electrocardiogram. The concomitant cardiovascular risk factors
include diabetes mellitus, dyslipidaemia, cigarette smoking, central obesity, microalbuminuria
or proteinuria, decreased GFR at less than 60 mL/min/m2, age of more than 55 in male and
 Muhammad Hafizuddin Bin Ahmad Razid
121303150
Klinik Kesihatan Peringgit

65 in female, and physical inactivity. The treatment for hypertension is initiated based upon
risk stratification of the individual patient.

Most hypertensive patients remain asymptomatic until complications arise. Potential

complications include stroke, myocardial infarction, heart failure, aortic aneurysm and
dissection, renal damage and retinopathy. The drug selection for the pharmacologic treatment
of hypertension would depend on the individual degree of elevation of BP and contradictions.

The non-pharmacological management of hypertension includes weight reduction,

reduction of salt intake, avoidance of alcohol, regular physical exercise, healthy eating, stop
smoking and relaxation therapy. All of these must be tried first before starting on any
pharmacological treatment. This is especially true for those who have low stratified risk and
hypertension stage 1.

Commonly used antihypertensive drugs include thiazide diuretics, -blockers, ACE

inhibitors, angiotensin receptor blockers, calcium channel blockers, direct vasodilators and -
receptor antagonists

In patient with newly diagnosed uncomplicated hypertension and no compelling

indications, choice of first line monotherapy includes ACEIs, ARBs, CCBs and diuretics which
have all been shown to reduce cardiovascular morbidity and mortality. Beta blockers are not
recommended as first line monotherapy in this group of patients. This is mainly due to an
earlier meta-analysis which showed that it is not as effective in lowering blood pressure and
in the prevention of stroke compared to the other antihypertensive agents. However, there are
many guidelines which recommend beta blocker as first line agent even in uncomplicated
newly diagnosed hypertension provided that the patient is young. Several other points should
be taken into consideration:

Those with intolerance or contraindication to ACE inhibitors and angiotensin receptor

blockers
Women of child bearing potential or
Patients with evidence of increased sympathetic drive

In patient with stage 1 hypertension, treatment should be started with monotherapy at low
dose. Monotherapy can lower BP to <140/90 mmHg in approximately 40 to 60% of patients.
If after sufficient period of treatment (up to 6 weeks) with monotherapy BP is still not controlled,
three options are available namely:

Increment of the dose of the initial drug

 Muhammad Hafizuddin Bin Ahmad Razid
121303150
Klinik Kesihatan Peringgit

Substitute the initial drug with another class of drug

A second drug to be added

Properly selected antihypertensive combinations may also mitigate the adverse effects of
each other. In patients presenting with stage 2 hypertension or beyond, combination therapy
as first line is recommended.

The follow up intervals should be individualized as well based on the stratified risk, pre-
treatment BP and drugs used. High risk and very high risk patients may have frequent follow
up to bring down the BP to target within 3 to 6 months. Once the target BP is reached follow
up at 3 to 6 months interval.

In conclusion, hypertension emerges as an extremely important clinical problem because

of its prevalence and potentially devastating consequences. The major classes of
antihypertensive drugs: diuretics, -blockers, CCB, ACE inhibitors and angiotensin receptor
antagonists, are suitable for the initiation and maintenance of antihypertensive therapy which
helps in reduction of cardiovascular morbidity and mortality.

Reflections

From this case, I learnt that hypertensive is one of the most common presentations in the
clinic. Be it hypertension alone or it can be presented together with diabetes mellitus or
hyperlipidemia. The most important thing to handle any case of hypertension or any illnesses
is patients knowledge to their current condition. As a physician, we may prescribe all kinds of
medications to control as well as prevent the disease from progressing but in the end, it all
comes back to the willingness of the patient to cooperate with a healthcare provider in order
to control/heal their illness.

Reference

I. Rashid, A. (2013). Clinical Practice Guidelines: Management of Hypertension (4th ed.).

Putrajaya: Ministry of Health Malaysia.

II. www.clevelandclinicmeded.com/medicalpubs/.../nephrology/arterial-hypertension/