Blood Pressure Management for Medical Student OSCE

1. Introduce, identify, explain, consent

2. Ask

   1. Noticed any symptoms of HTN such as headaches, vomiting, visual disturbances, fits?

   2. More than 2 raised bp readings on 2 separate occasions?

   3. Risk factors for bp?

      1. Smoking

      2. Stress

      3. Alcohol

      4. Weight

      5. Diet – cholesterol and salt

      6. Lack of exercise

   4. PMH – angina, MI, CVA, TIA

   5. FH

   6. DH for HTN – concordance / why not?

3. Medical advice – discussion of HTN with relation to the patient

   1. Why pt has HTN – possible reasons – relevant risk factors

   2. Lifestyle changes to adopt

      1. Smoking – reduce / quit

      2. Diet – healthier, low fat / salt

      3. Alcohol

      4. Exercise – regular e.g. daily 30 min brisk walk

      5. Weight – consider reducing to BMI 20-25 kg/m²

      6. Stress – alter environment / consult counsellor / relaxation techniques

   3. Investigations to request – identify end organ damage + 2? HTN causes

      1. Urine – glucose (diabetes), haematuria and proteinurea (renal disease)

      2. U&Es – renal impairment, Hyperaldosteronism

      3. ECG – myocardial ischaemia, left ventricular hypertrophy, angina

      4. CXR – cardiac failure, coarction of aorta (in young hypertensives)

   4. Treatment – taking into account class + dose of pt’s current medication – change dose / change class / add another class

British hypertensive society guidelines for treatment: sustained systolic >160mmHg or diastolic >100mmHg; OR sustained systolic >140mmHg, diastolic >90mmHg, with end organ damage, cardiovascular risk or DM. Mnemonic: ABCD

1.  
   1.  

      1. ACE inhibitors – not in renal artery stenosis (1^st line if <55yrs, not black)

      2. B-blockers – last resort (N.B. 1^st line in angina, except with asthma / COPD). Contraindications: mnemonic ABCDE! Only use when ACE inhibitors, Ca²⁺ channel blockers and diuretics are all already being used.

         1. Asthma

         2. Block (heart block)

         3. COPD

         4. Diabetes mellitus

         5. Electrolyte – hyperkalaemia

      3. Ca²⁺ channel blockers – side effects are bradycardia, headaches, ankle oedema

      4. Diuretics – long-acting thiazides / loop diuretics in renal disease

   2. Warnings: avoid NSAIDS, steroids, OCP/other oestrogen-containing drugs: can all elevate BP

2. Finishing off:

   1. Check understanding, ask for questions

   2. Follow-up: further appointment in several weeks. + Hypertensive support groups

   3. ‘I know it is a lot to remember all at once, but we can give you a leaflet detailing all the information, would you like that?’

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