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CASE PRESENTATION ON HYPERTENSION

Presented by
Bhavatharini P.A
II Pharm D
Bhavatharini
II Pharm D
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INTRODUCTION
 Hypertension is defined as a persistent elevation of blood pressure
above 140/90mmHg .
 It is known as a “silent killer” since it has no initial symptoms but can lead
to long term diseases and complications.
 Complications of hypertension include:
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Bp goals of jnc7 and jnc8 :
In general population aged > 60 years
Jnc7-140/90 mmHg
Jnc8-150/90mmHg
In young adults with diabetes or Ckd
Jnc7-130/90mmHg
Jnc8-140/90mmHg

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epidemiology
ETIOLOGY 5
PRIMARY HYPERTENSION:

 Also known as essential or idiopathic hypertension

 Result of unknown etiology

 Symptomatic treatment given

 Almost 90-95% patients show this type

SECONDARY HYPERTENSION:

 Result of some known pathology

 Occurs in about 5 -10% of patients

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PATHOPHYSIOLOGY
 HUMORAL MECHANISMS
Rennin Angiotensin Aldosterone mechanism:
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 Natriuretic hormone 8

Increased
concentration of natri
uretic hormone.

Inhibits Na/K ATPase

pump thus inhibits sodium
and water transport
across cell membrane.

Increase in blood
volume and blood
pressure.
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 Hyperinsulinemia: 9
 Insulin stimulates sympathetic actions.
 It has GH like properties- Cause hypertrophy of vascular endothelium.
 It causes Na and water retension.
 It increases intracellular Ca levels.
 increase Ch levels- Atherosclerosis.

 Anti Diuretic Hormone:

 Also known as Vasopressin.
 Released from the posterior pituitary gland.
 causes rise in BP.
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 NEURONAL MECHANISM: 10
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Diagnosis
 The evaluation of hypertension involves accurately measuring patient’s by
performing a focused medical history and physical examination.

Use auscultatory method with a properly calibrated instrument

Basic laboratory studies are performed to (1) identify or rule out causes of
secondary hypertension, (2) evaluate target organ disease, (3) determine
overall cardiovascular risk, or (4) establish baseline levels before initiating
therapy.
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TREATMENT
NON PHARMACOLOGIC:
Lifestyle modifications

 A relatively small reduction of BP of 2mmHg reduces the risk of stroke by

15% and CAD by 6%.

 Dietary changes: Average daily consumption of NaCl should not exceed

6g;this may reduce BP by 2-8mmHg

 DASH eating plan : Rich in fruits, vegetables, low fat dairy products, less
alcohol consumption and may lower BP by 8-14mmHg

 weight loss and exercise

PHARMACOLOGIC TREATMENT 13
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Subjective
 Patient Name: Ms. R

 Gender: F

 Age: 70 Yrs

 Ward: FM

 Date of Admission: 01/07/2017

 Date of Discharge: 04/07/2017

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Chief Complaints: 17
 C/o dyspnea x 3days
CH/O Chest discomfort
 Loose stools Past Medical k/c/o Type 2 DM
history : Systolic hypertension and IHD.
 Abdominal pain and
reduced oral intake
T.Clopidogral-75mg OD
Past Medication T.Glimipride-1mg OD
history Enalapril-2.5mg BID
T.Aspirin-75mg OD

Drug/Food Sociall history: Cooley

allergies: Nil Family history: Father died of heart attack.
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Objective
On examination: Patient conscious and oriented
 BP-150/100 mmHg
 RR-20/min ECG
 Temp:98.4o F
 CVS: S1, S2+
 RS: BAE+
 CNS: NFND
 P/A: Soft
LAB VALUES 19
PARAMETER RANGE NORMAL RANGE

Total WBC count 17.1 x 103 3.2-9.8 x 103

cells/mm3 cells/mm3
Polymorphs 84% 54-62 %
Fasting blood 158 mg/dL <100 mg/dL
sugar
Postprandial 294 mg/dL <140 mg/dL
blood sugar
Random blood 355 mg/dL <200 mg/dL
sugar
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Assessment
Hypertension with Type 2 Diabetes Mellitus.
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Plan
Drugs prescribed on day 1 (7 a.m.)
Sl.No Drugs name Dose Frequency

1. T. Spiranolactone 50 mg OD 1-0-0

2. T. Metformin 500 mg BID 1-0-1

3. T. Glimepride 1 mg BID 1-0-1

4. T. Aspirin 75 mg OD 0-1-0

5. T. Clopidogral 75 mg OD 1-0-0

6. T. ISDN 5 mg TDS 1-1-1

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Date On Patient Drugs prescribed Dose Frequency
examination complaints

1st July BP- c/o Inj. Furosimide 20mg BID

190/120mm breathing
Hg difficulty Inj. Deriphyllin 100mg BID
PR-84 Chest
RR-20 pain Inj. Taxim 1g BID
T-98.4 Difficuty
SPO2 -88% to walk Salbutamol Neb - Q6h
in room air
RS-B/L T.Amlodipine 2.5mg OD
crepts
Inj.Ranitidine 2cc BID

Inj.metronidazole 200mg TDS

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2nd July BP- No new Repeat all.
160/70mmHg complaints
PR-88 .Patient can be
RR-20 shifted to FM
SPO2-94% Ward.

3rd July BP-150/70 No new Repeat all

PR-85 complaints
RR-24
FBS-110mg/dl
Ppbs-185mgdl
No new
4th July BP-140/70 complaints
PR-88 ,patient can be
RR-22 discharged.
Discharge Medications: 24
Drug name Dose Frequency

T. Enalapril 5 mg ½-0- ½

T. Furosimide 20 mg ½-½-0

T. Spiranolactone 50 mg 1-0-0

T. Salbutamol 4 mg 1-0-1

T. Deriphylline 100 mg 1-0-1

T. CPM 16 mg 0-0-1
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Interventions
 Patient has a high risk of MI as she's a k/c/o IHD and her polymorph count is high.
Therefore, lipid profile test should be carried out.

Patient has a past medication history of enalapril. But, serum K+ level is not monitored.

 Atorvastatin can be included in the first day’s prescription and discharge plan.

 Amlodipine is not the right drug of choice for this patient. It can be substituted with
Captopril as patient’s BP is 190/120 mmHg on the first day at 8 a.m.– hypertensive crisis,
appropriate treatment with oral Captopril may be considered to reduce BP by 25%.
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 Patient did not complain of any allergic rhinitis and thus, CPM is not indicated.

 Lasix given in the discharge plan may be changed to hydrochlorothiazide as this patient has
DM.

 Enalapril is prescribed as half tablet in the discharge plan. This maybe changed to 2.5 mg
tablets to improve medication adherence.

 T. Salbutamol may have adverse effects in ischemia and so switching it to inhaler may be
considered.

 Random blood glucose level is 355mg/dl which is high. Therefore administration of insulin may
be recommended. (According to ADA guideline insulin therapy should be started if HbA1c is above
9%).Therefore HbA1c levels should be checked, and it should be repeated every 2-3 months to
confirm medication adherence and to consider replacing the oral hypoglycemic agents with insulin.
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Pharmaceutical care plan

DURING HOSPITAL STAY:
 Lipid profile test to be done on the day of admission.
 Insulin -10 units on the day of admission.
 T. Attorvastatin-20mg- 0-0-1 to be added to the prescription.
 T. Captopril-12.5mg-OD ( replace Amlodipine).
Sl. Drugs Dose ROA Frequency Day Day Day Day 28
No. 1 2 3 4
1. T. Spiranolactone 50mg Oral OD
2. T. Aspirin 75mg Oral OD
3. T. clopidogrel 75mg Oral OD
4. T. Atorvastatin 20mg Oral OD
5. Inj. Lasix 20mg IV BD
6. T. Captopril 12.5mg Oral OD
7. Inj. Insulin 16 units s.c OD
8. T. Metformin 500mg Oral BD
9. T. Glimipride 1mg Oral BD
10. Inj. Deriphyllin 100mg IV BD
11. Salbutamol Neb 0.083% Nasal Q6hrs

D
12. Inj. Metronidazole 200mg IV TDS
13. Inj. Ranitidine 2cc IV BD
14. Inj. Taxim 1g IV BD
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DISCHARGE:
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 Hydrochlorothiazide-12.5mg-OD-1-0-0.(replace lasix), add Metformin and Atorvastatin
 Salbutamol inhaler-180mcg(2 puffs) q6hr.
Drug Dose Frequency
T.Enalapril 2.5mg 1-0-1
T.Hydrochlorothiazide 12.5mg 1-0-0
T.Spiranolactone 50mg 1-0-0
T.Deriphyllin 100mg 1-0-1
Salbutamol inhalor 180mcg (2 puffs) q6hrs
T.Metformin 500mg 1-0-1
T.Glimepride 1mg 1-0-0
T.Atorvastatin 20mg 0-0-1
T.Clopidogrel 75mg 1-0-0
T.Aspirin 75mg 0-0-1
T.Omeprazole 20mg 1-0-0
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Monitoring parameters
Lasix,thiazide –electrolytes,blood glucose.

Salbutamol,deriphyllin- HR,BP.

ISDN-BP

`Enalapril- electrolytes,renal function.

 Aspirin,clopidogral-bleeding and clotting time.

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Patient counseling
REGARDING DISEASE
 Hypertension is increased blood pressure and

Diabetes is increased blood sugar level.

 Complications of these disorders include heart, kidney, brain, nerve and eye
diseases.

 Both diabetes and hypertension are disorders and can just be treated and not
cured.

 Disease may be precipitated due to lack of lifestyle modification, irregular intake

of medications and check-ups.
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LIFESTYLE MODIFICATIONS 32
 Patient was advised to consume a diet rich in fruits, spinach, pulses, cereals, fibres,
vegetables, avoid taking oily, canned/preserved food, carbohydrates, sweets, reduce drinking
coffee/tea.

 Patient was advised to reduce daily dietary sodium intake as much as possible, (ideally to 1.5
g /day).

 Patient was advised to regularly do mild physical activity (at least 30 min/day, most days of the
week),and avoid vigorous activity.

 Patient was advised about diabetic foot care, to check feet every day to wash every day to
keep skin smooth and soft, trim toenails, keep feet up while sitting, make an habit of wearing
slipper always.
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DRUG RELATED 33
 Patient was insisted to continue taking the medications as directed by the physician even if
she feels better because hypertension is asymptomatic.

 Incase of missed doses take them as soon as you remember. Skip them if it is almost time for
the next scheduled dose. Do not take extra medication to make up the missed dose.

 Avoid getting up too fast from sitting or lying position, or you may feel dizzy because of anti
hypertensive drugs, get up slowly and steady yourself to prevent a fall.

 Patient was educated about the adverse drug effects and warnings.

 Enalapril- asked to report immediately if angioedema (swelling of the tongue) occurs on buying
medications make sure with the pharmacist that it can be taken with Enalapril. (e.g.: NSAIDS
show antagonism).
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Diuretics-Might make you urinate more often so do not take at nights, avoid
being overheated or dehydrated. Take Aldactone with a full glass of water. High
doses of Furosemide can cause irreversible hearing loss.
 Aspirin and Clopidogrel- Take them after food, avoid activities that will
increase the risk of bleeding and injury, if you need a surgery or dental work tell
the doctor that you are taking these drugs, call your doctor if you have bleeding
that will not stop. Aspirin shouldn’t be taken with NSAID’s.
 Omeprazole should be taken 30 min before food.
 Glimepride, Metformin might cause hypoglycemia. Symptoms include
headache, hunger, weakness, sweating, tremor. Always have a source of sugar
and take it when you feel the symptoms. Take them after food.
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Deriphylline-might reduce alertness, drinkin/eating food rich in caffeine increase the side
effects.

 Salbutamol Inhaler- direction of use was explained and points to remember such as:

The canister should always fit firmly in the actuator.

Breathe in deeply and slowly to make sure you get all the medicine.

Hold your breath for about 10 seconds after breathing in the medicine. Then breathe out fully.

Always keep the protective cap on the mouthpiece when your inhaler is not in use.

Always store your inhaler with the mouthpiece pointing down.

Clean your inhaler at least 1 time each week.

Store the drugs in a cool and dry place away from direct heat and sunlight.
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