SIU School of Medicine

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Department of Internal Medicine

Hypertension

Rationale

As many as 50 million Americans have elevated blood pressure or are taking antihypertensive medication. Nonfatal and fatal cardiovascular disease including coronary heart disease (CHD), stroke and renal disease all increase progressively with higher levels of both systolic and diastolic blood pressure levels. These relationships are strong, continuous, independent, predictive and etiologically significant, and indicate that reduction of blood pressure reduces these risks.

Prerequisites

Prior knowledge of the:

  • Pathogenesis and pathophysiology of hypertension
  • Epidemiology and risk factors of hypertension
  • Pharmacology of the major classes of antihypertensive drugs

Knowledge

Students should be able to:

  • identify the etiologies and relative prevalence of primary and secondary hypertension
  • define hypertensive urgency and emergency, citing examples of both
  • define and describe the manifestations of target-organ disease due to hypertension
  • define the classification of blood pressure (systolic blood pressure [SBP], diastolic blood pressure [DBP]) for all age 18 or older:
    • young adult
    • middle age
    • the elderly
  • describe basic approaches to the pharmacological management of acute and chronic hypertension, including:
    • the physiologic basis and scientific evidence supporting these approaches
    • causes for lack of responsiveness to therapy
  • describe the prevention strategies for reducing hypertension (including lifestyle factors such as dietary intake of sodium, weight and exercise level) and explain the physiologic basis and/or scientific evidence supporting each strategy
  • describe steps in management of patients with a hypertensive emergency

Skills

Students should demonstrate specific skills, including:

  • History-Taking Skills: Students should be able to obtain, document, and present a medical history that differentiates among etiologies of hypertension including:
    • duration and levels of elevated blood pressure
    • history of symptoms of:
      • cardiovascular disease
      • cerebrovascular disease
      • renal disease
      • diabetes
      • dyslipidemia
      • gout
    • history of symptoms suggesting secondary hypertension
    • history of:
      • weight gain
      • leisure-time physical activities
      • smoking or other tobacco use
    • family history of:
      • high blood pressure
      • premature CHD
      • stroke
      • CVD
      • diabetes mellitus
      • dyslipidemia
    • psychosocial and environmental factors that may elevate blood pressure:
      • family situation
      • employment status
      • working conditions
      • education level
    • dietary assessment including:
      • sodium intake
      • alcohol use
      • intake of saturated fat
      • intake of cholesterol
    • results and side effects of previous antihypertensive therapy
    • use of commonly prescribed, over-the-counter, and illicit medications that may raise blood pressure or interfere with the effectiveness of antihypertensive medications
  • Physical Exam Skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease including:
    • blood pressure measurements to detect and confirm the presence of high blood pressure
    • examination of the fundus for:
      • arteriolar narrowing
      • arteriovenous nicking
      • hemorrhages
      • exudates
      • papilledema
    • examination of the neck for:
      • carotid bruits
      • distended veins
      • enlarged thyroid gland
    • examination of the heart for:
      • increased rate
      • increased size
      • precordial heave
      • clicks
      • murmurs
      • arrhythmias
      • third (S3) and fourth (S4) sounds
    • examination of the abdomen for:
      • bruits
      • enlarged kidneys
      • masses
      • abnormal aortic pulsation
    • examination of the extremities for:
      • dimished, delayed or absent peripheral arterial pulsations
      • bruits
      • edema
    • peripheral pulses specifically femoral arterial pulses
    • body habitus, looking for changes associated with secondary hypertension
    • peripheral and central nervous system for ischemic changes

  • Differential Diagnosis: Students should be able to generate a prioritized differential diagnosis recognizing specific history and physical exam findings that suggest a specific etiology.
  • Laboratory Interpretation: Students should be able to recommend and interpret diagnostic and laboratory tests.
    • Students should understand the rationale for and correctly identify abnormalities detected by the following tests.
      • urinalysis
      • complete blood count
      • blood glucose
      • potassium
      • calcium
      • creatinine
      • uric acid
      • cholesterol, HDL, LDL and triglycerides
      • electrocardiograph
  • Communication Skills: Students should be able to:
    • communicate the diagnosis, treatment plan, and prognosis of the disease to patients and their families, and consider the patient’s knowledge of hypertension, and preferences regarding treatment.
    • educate patients about hypertension reisk factors, taking into account:
      • demographics
      • concomitant diseases and therapies
      • quality of life
      • physiologic and biochemical measurements
      • economic considerations

  • Basic and Advanced Procedure Skills: Students should be familiar with how to insert a nasogastric tube after explaining the procedure to the patient and obtaining appropriate consent.
  • Management Skills: Students should be able to develop an appropriate evaluation and treatment plan for patients with:
    • acute and chronic hypertension
    • primary hypertension
    • secondary hypertension
    • Students should be able to prescribe preventive strategies to diminish hypertension, including:
      • weight reduction
      • moderation of alcohol intake
      • regular physical activity
      • reduction of sodium intake
      • increase in potassium intake
      • smoking cessation
    • Students should be able to access and utilize appropriate information systems and resources to help delineate issues related to hypertension.

Attitudes and Professional Behaviors

Students should be able to:

  • appreciate the importance of patient preferences and compliance with management plans for those with hypertension
  • appreciate how preventive strategies may diminish need for medications
  • appreciate the importance of side effects of medications and their impact on quality of life and compliance, including those side effects to which the geriatric population may be more prone

Resources

  • “The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure”, JAMA, May, 2003, 289, No 19. See Clerkship weekly articles, week one
  • “Diuretic Therapy”, Brater, D.C, NEJM, August, 1998, Vol. 339, No. 6. See Clerkship weekly articles, week three
  • Clinical Management Conference, E. Constance, MD
  • Internal Medicine Clerkship Guide, Paauw, et al, Mosby 2003, pp 404-414

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