nephro_______3? - goal13

[ArchivalUser]

A 41-year-old woman is evaluated during a routine office follow up clinic visit . She is a vegetarian and does not smoke cigarettes. She feels well except for an occasional tension headache. She takes no medications.

On physical examination, blood pressure is 138/94 mm Hg, which is similar to the values measured at her initial visit. Other vital signs are normal. BMI is 21. The remainder of the examination is unremarkable.

Laboratory studies reveal normal electrolytes, complete blood count, fasting glucose, and fasting lipid profile as well as normal kidney function.

Electrocardiogram is unremarkable.She was given a prescription of HCTZ by her PCP and was sent home.
Which of the following is the most appropriate next step in the management of this patient's hypertension?

A Reassess her B.P in 2 weeks

B Reasses her in 3 months

C 2D ECHO at current/follow up visit

D Add B blocker to HCTZ

[ArchivalUser]

something's off in the question ... 1st it mentions that its a routine follow up visit .. later it mentions that she was given a HTN med by her PCP .. did she change PCPs in the question?

if the above is assumed .. then choice A .. reassess the BP in 2 weeks and make sure she actually has HTN (considering everything else in the q. stem is normal / WNL)

[ArchivalUser]

agree with doctam3.

Pt should have at least 3 bp measurements at least 3 weeks apart (measurements should be above 140/90)
doctor's first advice should be life style changes (since her bp is not sky high), then doc should proceed to hctz..but then again, it doesnt make sense giving her medication right away after the 2nd measurement of bp.
something is off with that question.

[ArchivalUser]

@doctam3

Nothing wrong with question

A follow up visit does not mean a change in PCP.The stem never mentions that.

She was given anti HTN medication by her PCP because B.P was similar to her initial visit preceeding the follow up i.e current visit.

When she was started on Anti HTN she was diagnosed to have HTN .There is no further need to confirm that she has HTN.

[ArchivalUser]

@medstudent85

Your statement "Pt should have at least 3 bp measurements at least 3 weeks apart (measurements should be above 140/90)" is not true.

Refer to JNC 7th guidelines

http://www.nhlbi.nih.gov/guidelines/hype...c7full.pdf

Page 18 .( average of two readings is suffcient to label a person as HTN)

If you disagree correct me

Thnx

[ArchivalUser]

Please read the following.It says the measurement from initial screen is not included.

Hypertension — The following definitions were suggested in 2003 by the seventh report of the Joint National aeCommittee (JNC 7) based upon the average of two or more properly measured readings at each of two or more visits after an initial screen :

Treatment(According to uptodate.com)

Who should be treated? — Using the above definitions from JNC 7, the following general approach can be used to determine which patients with hypertension require antihypertensive therapy [4,52,53]. This approach largely includes the recommendations of JNC 7 for risk stratification and treatment and assumes accurate measurement of the blood pressure (table 7) [4]. A review of the potential errors involved with the procedure of blood pressure measurement is available elsewhere. In the absence of end-organ damage, a patient should not be labeled as having hypertension unless: the blood pressure is persistently elevated after three to six visits over a several month period; hypertension is revealed by 24-hour ambulatory monitoring; or the average of home blood pressure readings taken in the morning and evening daily for seven days is elevated. (See "Blood pressure measurement in the diagnosis and management of hypertension in adults" and "Ambulatory blood pressure monitoring and white coat hypertension in adults".)

All patients should undergo appropriate nonpharmacologic (lifestyle) modification (table 8). (See 'Nonpharmacologic therapy' below.)

The following decisions about antihypertensive medications are generally not made until there has been an adequate trial of nonpharmacologic therapy. (See "Hypertension: Who should be treated?".)

●Antihypertensive medications should generally be begun if the systolic pressure is persistently ≥140 mmHg and/or the diastolic pressure is persistently ≥90 mmHg in the office and at home despite attempted nonpharmacologic therapy [4,54,55]. (See "Hypertension: Who should be treated?".)

●Starting with two drugs should be considered in patients with a baseline blood pressure above 160/100 mmHg. This strategy may increase the likelihood that target blood pressures are achieved in a reasonable time period, but should be used cautiously in patients at increased risk for orthostatic hypotension (such as diabetics and the elderly). (See "Choice of therapy in primary (essential) hypertension: Recommendations".)

●Patients with office hypertension, normal values at home, and no evidence of end-organ damage should undergo ambulatory blood pressure monitoring to see whether they are truly hypertensive. (See "Ambulatory blood pressure monitoring and white coat hypertension in adults".)

As noted above, the benefits of antihypertensive therapy are less clear or controversial in patients who have mild hypertension (blood pressure less than 150/90 mmHg) and no preexisting cardiovascular disease, and in elderly patients who are frail. (See "Hypertension: Who should be treated?", section on 'Low-risk patients' and "Treatment of hypertension in the elderly patient, particularly isolated systolic hypertension", section on 'Problem of frailty'.)

Nonpharmacologic therapy — Treatment of hypertension should involve nonpharmacologic therapy (also called lifestyle modification) alone or in concert with antihypertensive drug therapy (table 8).

[ArchivalUser]

Guidelines from update (taken from JNC 7)

Cut paste form "uptodate"

Number of readings
*****************

Take at least two readings on each visit, separated by as much time as possible; if readings vary by more than 5 mm Hg, take additional reading until two consecutive readings are close

For the diagnosis of hypertension, take three readings at least one week apart

Initially, take blood pressure in both arms; if pressures differ, use the higher arm

If the arm pressure is elevated, take the pressure in one leg, particularly in patients under age 30 years

It says three readings not three visits .

[ArchivalUser]

These are USPSTF guidelines for diagnosing HTN

http://annals.org.ezproxy.rush.edu/artic...eid=737820

view large the figure and see the table that clearly mentions the definition of HTN.

[ArchivalUser]

Exactly,. Yup..3 readings at least one week apart

[ArchivalUser]

So where in the stem you got the information that B.P readings were not out of three readings.