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INTRODUCTION

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CASE LEARNING OBJECTIVES

  • Classify blood pressure levels and treatment goals

  • Recognize contributing factors in uncontrolled hypertension

  • Recommend appropriate lifestyle modifications and pharmacotherapy for patients with uncontrolled hypertension on the basis of individual patient characteristics

  • Construct an appropriate monitoring plan to assess hypertension treatment

  • Properly educate a patient about antihypertensive treatment

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PATIENT PRESENTATION

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Chief Complaint

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"My blood pressure at home is still high."

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History of Present Illness

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Gusto Roubaix is a 66-year-old black male who presents with his wife to his health care provider complaining that his home BP readings continue to remain high. He was diagnosed with HTN 10 years ago, and it was well controlled until the past 18 months. He blames this on stress related to a poor real-estate market and a significant [>30 lb (>13.6 kg)] weight gain over the past 5 years (tries to practice portion control but dines out frequently; he does not have salt at the table or cook with salt). He is frustrated because his BP has not improved despite 1 hour of light aerobics (walking and water aerobics) daily, over the past 6 months. His home BP log, which he brought with him, reveals resting seated systolic BP levels ranging from 130 to 155 mm Hg and diastolic BP levels ranging from 70 to 90 mm Hg and a pulse of 50 to 58 bpm in the morning over the past 30 days. In addition, despite restricting his calories, he has not lost any weight. He complains of excessive fatigue, and his wife states she is always tired as well, as his snoring "keeps the whole house up all night long." He denies any dizziness or lightheadedness, edema, chest pain, or shortness of breath.

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Past Medical History

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HTN (diagnosed 10 years ago)

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Impaired fasting glucose

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Metabolic syndrome

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Dyslipidemia

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Osteoarthritis of the knees (unresponsive to high-dose acetaminophen)

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History of gout

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GERD

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Obstructive sleep apnea

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BPH

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Obesity

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"Stress/fatigue"

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Family History

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Mother deceased, stroke at age 82. Father is alive and well, aged 86. Sister diabetes and CKD, aged 59. Brother alive and well, aged 63.

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Social History

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Lives in South Florida year round with his wife of 40 years.

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Tobacco/Alcohol/Substance Use

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Social drinker, one to two glasses of wine nightly, (−) tobacco products, (−) illicit drugs.

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Allergies/Intolerances/Adverse Drug Events

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Penicillin (angioedema)

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Medications (Current)

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Aspirin 81 mg PO q am

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Verapamil SA 240 mg PO q 24 h

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Metoprolol Succinate SA ...

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