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8. 54-year-old male with elevated blood pressure- Mr. Martin

Terms in this set (39)

G. Reveal identifiable causes of high blood pressure such as: sleep apnea, chronic kidney disease, primary aldosteronism, renovascular disease, pheochromocytoma, coarctation of the aorta, and thyroid or parathyroid disease.
H. A review of all medications, including OTC and complementary medications is crucial. Some common prescription medications like:
1. birth control pills, amphetamines, thyroid medications, steroids, and certain anti-depressants may elevate blood pressure.
Some common OTC meds can also elevate blood pressure, such as:
2. pseudoephedrine, appetite suppressants, or NSAIDS. Some herbal remedies may elevate blood pressure such as:
3. ma huang, bitter orange, ginkgo, ginseng, licorice, and St. John's wort.

As noted above, cocaine and ketamine use, narcotic withdrawal, excessive alcohol intake and smoking can also elevate blood pressure.

Other appropriate questions include:
1. Family history of diabetes and / or hypercholesterolemia
2. Patient's diet history
3. A review of psychosocial stressors.
- Stress directly causes the release of angiotensin II and norepinephrine in the body (flight or fight syndrome), and stressors can also make prioritizing adherence to blood pressure medicines difficult.

Answers B (personal history of cancer), F (personal history of glaucoma), and H (family history of colon cancer) are not essential elements of an initial focused history for a patient with a possible new diagnosis of hypertension. These questions are appropriate however for a more general medical history.
Thiazide diuretics may cause elderly patients to become incontinent of urine
- Aging decreases bladder capacity, decreases time of awareness of need to void, increased detrusor instability decreased pelvic floor muscles, incomplete emptying, and atrophic urethral changes.
- Thiazide diuretics may exacerbate problems for those on the threshold or already incontinent of urine.

Thiazides have demonstrated marked reduction in morbidity and mortality from hypertension
- low-dose (12.5 to 25 mg/d chlorthalidone or hydrochlorothiazide) and high-dose (50 mg/d or more of both drugs) diuretic therapy lowered blood pressure to a similar degree and exerted a similar benefit in reducing stroke, congestive heart failure, cardiovascular, and total mortality
- only low-dose diuretic therapy significantly reduced coronary heart disease incidence. Chlorthalidone is a thiazide-like diuretic.
- A 2009 Cochrane review reinforced that no other drug class improved health outcomes better than low-dose thiazides, and beta-blockers and high-dose thiazides were inferior.
- In addition, low-dose inexpensive thiazides should be the first choice drug in most patients with elevated blood pressure.

- Thiazide diuretics should be started at lower doses in elderly patients such as 6.25mg or 12.5mg (NOT 25 mg) a day, because this population may be more sensitive to this drug class and may experience hypotensive episodes.
- Most other adults can start at 25mg per day. Although elderly patients start at lower doses, they may require the same amount of medication as younger persons to control their blood pressure.

Remember that JNC 8 does not single out thiazide diuretics as the first choice anti-hypertensive for most patients. Instead, the JNC 8 includes thiazide diuretics as a recommended option for all patients except those with chronic kidney disease (ACE/ARBs)