Hypertension

Identification & demographic details:

● Name:

● Age:

● Sex:

● Religion and caste:

● Education:

● Address:

● Occupation (both present and past, duration)

● Nearest health facility:

Family members

Pedigree chart

SES

History of presenting illness:

Complaints of ____________ since ______ days/ months/ years. (In chronological order)
My patient was apparently alright then he developed _____________ (name of the symptom) which
was insidious/ sudden in onset, progressive/ non-progressive in nature. (Describe each symptom in
detail with treatment history if taken). There is no history of _______________________. (Ask & write
the negative history based on probable causes.)
● Headache: +/-

● Dizziness: +/-

● Dyspnea: +/-

● Angina: +/-

● Palpitation: +/-

● Blurred vision: +/-

● Edema: +/-

● Tremors: +/-
History of treatment before admission: +/-
If yes, nature of treatment
If treatment has discontinued, reasons

Past History:
H/o of previous illness or hospitalization for similar complaint
● Timing of illness
● nature
● hospitalization
● complications
● treatment
● Major operation
Treatment history:
FBS/ PPBS/HbA1c, Total cholesterol, Triglycerides, HDL, LDL, ECG, Urine albumin and sugar, urea,
creatinine, cancer screening, fundoscopy

Personal history:
● Diet: Veg/ Mixed/ Vegan

● Salt intake:

● Saturated fat intake:

● Appetite: Normal/ Increased/ Decreased

● Bowel & bladder: Regular/ Irregular

● Sleep: Adequate/ Increased/ Decreased

● Physical exercise: Regularly/ Infrequently/ No, duration (min/day and days/week)

● Regular health checkup

● Addiction:
o Yes/ No (If yes, then specify Gutkha/ Pan-masala/ Tobacco chewing/ Smoking/ Alcohol/
IV drugs)
o Age of initiation
o Reason for starting
o Daily quantity
o Duration: ___
o Side effects/ disadvantages felt
o Efforts to quit
● If female, ask about menopause and obstetric history

Diet history
● Any dietary restrictions: sugar, salt, fats

● Total calories and proteins

● Intake of salt and fat

Epidemiological history:
● age at the onset of symptoms

● duration between onset and diagnosis

● duration between diagnosis and start of treatment

● prevalence of similar disease in the locality

Family history:
 ● Non communicable diseases: +/-

● If yes specify: DM/HTN/CHD/COPD/ Asthma/ Cancer/others

● Genetic background

● If present, degree of relationship

Environmental history

Psychosocial history
● Symptoms of depression

● Family support

● Any discrimination or difficulty faced due to the disease

General examination:
● Conscious, cooperative, well-oriented to time, place and person
● Built: well/ fair/ poor
● Nutrition: well/ fair/ malnourished
● Anthropometry: height, weight, BMI, WHR

Vitals
● Blood pressure (BP): ___________ mm Hg (At various postures)

● Pulse rate (PR): __________ beats/ min

● Respiratory rate (RR): __________ cycles/ min

● Temperature: ___________ degree F

● Pallor: Yes/ No

● Icterus: Yes/ No

● Clubbing: Yes/ No

● Cyanosis: Yes/ No

● Lymphadenopathy: Yes/ No

● Edema: Yes/ No

● Anthropometry:

● Built:

● Nourishment:
 ● Height: _________m

● Weight: ________kg

● BMI: __________ kg/ m2

● Waist hip circumference

Systemic examination:
● RS

● CVS

● CNS

● Abdomen

● Other relevant system

Examination specific to hypertension:

● Eyes

● Renal system

● Endocrinal

Epidemiological diagnosis:

Lab investigations:
● ECG- LV hypertrophy and IHD

● Echocardiogram- LV functions and coarctation of aorta

● Urine analysis- proteinuria, hematuria

● x-ray chest- aorta

● lipid profile

● IVP- Renal tumor and stones

● Abdominal sonography- Polycystic kidney

Clinical diagnosis
A ___________ yr old male/ female _________ suffering from (primary/ secondary) HTN (CATEGORY)
under control/ or uncontrolled, regular or irregular treatment, __________comorbidities. He/she is an
elderly person with _______ vision, _______ hearing & ADL score______. Compliance towards diet,
medication and lifestyle modification________:

Web of causation
Levels of prevention:

Levels of prevention Which level has failed How it could be

prevented?
primary Health promotion
Specific protection
Secondary Early detection and
prompt treatment
tertiary Disability limitation
rehabilitation

Assessment of knowledge, attitude, and practice (KAP) towards the disease:

particulars knowledge Attitudes practice

(Beliefs and customs)
Cause of hypertension
Treatment
Prevention
Health services
Stigma

Influence of medico social factors in diagnosis, treatment, and prevention of the disease:

Impact of the disease on socio economic status of

● Family

● Community

● Nation

Medico social diagnosis:

MANAGEMENT:
Primordial prevention:
● Population strategy and high-risk strategy – reduction of risk factors
● Secondary prevention: early detection and treatment
● Tertiary prevention: organizing specialized rehabilitation clinics

Treatment plan:
Individual level:
Nonpharmacological:
● lifestyle modifications

● Maintain sugar level, weight

● salt restriction < 5 g/day

 ● Avoid oily food (sweets, oily foods, cheese, paneer, butter) Aur namkeen bhi

● Weight reduction: reduction of 1 kg body weight will reduce 1.6/1.3 mmHg of BP

● stop smoking

● diet:
o food rich in PUFA, potassium, calcium, magnesium
o reduced saturated fat and cholesterol
o fruits, vegetables, green leafy vegetables
o limiting alcohol intake < 30 ml/day
● relaxation

● regular exercise, yoga

● Diabetics: 6 monthly HbA1c, foot care (avoid barefoot walking), RFT and ophthalmological
examination annually, avoid high glycemic index foods, small quantity and higher frequency of
food

Pharmacological:
periodic examination and follow-up

Family level:
● Motivate the patient to take proper diet and drugs

● Motivate the patient for periodic checkup

● Family members: to undergo regular screening for hypertension

Community level:
● preventing emergence of risk factors (primordial prevention)

● early diagnosis and prompt treatment

● genetic counselling

● healthy lifestyle

● periodic health checkup

● regular monitoring of weight, BP, and blood sugar

Old age specific Advice:

● Adopt a positive attitude towards ageing (spiritual)

● Fall prevention: careful while going to bathroom & climbing stairs

● Socialise with family, relatives & neighbours

● Social schemes: old age pension scheme, widow pension scheme etc ( if eligible)

● If Osteoarthritis is present: Explain that it is a disease of old age, pain can only be controlled but
not cured completely, pain killer can be harmful and should be taken only on advice by a doctor,
exercises like muscle strengthening will help, to be ambulatory as much as possible, use walking
stick
 Important points

Programs related to NCDs:

National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Disease
and Stroke (NPCDCS)

- Maintain sugar level

- Maintain weight
- Do regular exercise, yoga
- Avoid oily food, sweets, cheese, paneer, butter
- Do not take more salt (Avoid pickles, papad like salty foods)
- Avoid spicy food
- For diabetic patients: Every 6 monthly get tested for glycosylated hemoglobin (HbA, C)
- Take care of your feet, avoid barefoot walking
- Regularly go for eye check up at least once a year and kidney check up
- Avoid foods with high glycemic index food like sweet potato
- Small amount and more frequency of food should be practiced.

WHO classification of obesity

For children under 5 years of age:
- Overweight: weight-for-height >2 SD above WHO Child Growth Standards reference median
- Obesity: weight-for-height >3 SD

For children aged 5-19 years:

- Overweight: BMI-for-age > 1 SD
- Obesity: >2 SD
As per WHO data 1 in 3 is overweight and 1 in 10 is obese

Special questions regarding hypertension:

1. Classification and goal of blood pressure
2. Blood pressure measurement technique
3. Rule of half
4. Tracking of blood pressure
5. Drugs commonly used for the treatment of hypertension
6. DASH strategy
Classification of hypertension (JNC 8)

Hypertension guideline in brief

● ≥ 60 years who do not have any other comorbid condition, the goal of BP is < 150/90
mm Hg
● 18-59 years of age without other major comorbidities and ≥ 60 years who have other
comorbid condition, such as diabetes, chronic kidney disease, the goal of BP is < 140/90
mm Hg.

Blood pressure measurement technique

● In clinic: Two readings to be taken sitingin chair, 5 minutes apart and confirmation in.
elevated reading can be made by measung. blood pressure in contralateral arm.
● Ambulatory BP monitoring; it is indicates to rule out "white coat hypertension"

Rule of half: Only about half of the suben, in general population are aware of having, high
blood pressure, only half of those awat. of the problem are being treated and only half of those
being treated are considered as adequately treated.

Tracking of blood pressure: It means high BP during childhood tends to remain high as
individual grows older and in the same way low BP tends to remain low during adulthood. So
the track of blood pressure remains on the same pathway as taken in childhood to the
adulthood.
Drugs commonly used for the treatment of hypertension: ACE Inhibitors, beta blockers.
diuretics, alpha blockers, etc.

DASH strategy: Dietary Approaches to Stop Hypertension is a diet plan that is rich in fruits,
vegetables, fibers, minerals and low in saturated fat, trans fat and sodium. In this strategy, diet
plan is decided as per the level of activity and age. It is very much importan that aerobic
exercise should be complementing this DASH plan to have good results in lowering blood
pressure.

Lifestyle Recommendations to Control High Blood Pressure: