Pharmacotherapy Case Study: Hypertension by Dr. Nehad Jaser
Subjective Data
·
Chief Complaint: “I’ve
had headaches and dizziness for the past 2 weeks. Sometimes I feel pressure in
my chest too.”
·
History of Present Illness:
o
Intermittent occipital headaches
(3–4×/week), worsening with activity.
o
Episodic non-exertional chest
discomfort (no radiation).
o
No syncope, palpitations, or visual
changes.
·
Medical History: Diagnosed
with hypertension 2 years ago. No diabetes, CKD, or heart disease.
·
Family History: Father
with hypertension; mother with stroke at age 70.
·
Medications: Hydrochlorothiazide
(HCTZ) 25 mg daily (admits to inconsistent use).
·
Lifestyle:
o
Diet: High in processed foods and
added salt.
o
Physical activity: Sedentary (desk
job, no exercise).
o
Alcohol: 4–5 beers/week.
o
Smokes 1 pack/day × 30 years
(attempted quitting 5 years ago).
·
Adherence: Misses
HCTZ doses “3–4 times a week due to forgetfulness.”
Objective Data
·
Vitals:
o
BP: 160/100 mmHg (average of two
readings, seated).
o
HR: 78 bpm, BMI: 30 kg/m², waist
circumference: 40 inches.
·
Physical Exam:
o
Cardiovascular: Regular rate/rhythm,
no murmurs.
o
Lungs: Clear bilaterally.
o
Extremities: No edema.
·
Labs:
o
LDL: 145 mg/dL, HDL: 42 mg/dL,
triglycerides: 160 mg/dL.
o
Fasting glucose: 98 mg/dL; HbA1c:
5.8%.
o
Serum K⁺: 3.3 mEq/L (low),
creatinine: 0.9 mg/dL, eGFR: 88 mL/min/1.73m².
o
Urinalysis: No protein/blood.
·
ECG: Left
ventricular hypertrophy (LVH).
Assessment
1.
Primary Diagnosis:
o
Stage 2 Hypertension (BP
160/100 mmHg) with poor adherence to HCTZ.
o
Contributing Factors: Obesity,
high-sodium diet, alcohol use, sedentary lifestyle.
2.
Complications:
o
Target Organ Damage: LVH
on ECG.
o
Hypokalemia (likely
HCTZ-induced).
3.
Risk Stratification:
o
ASCVD 10-year risk: Elevated
(smoking, LDL, borderline HbA1c).
Pharmacotherapy Plan
1.
Medication Adjustments:
o
Discontinue HCTZ 25 mg daily (due
to non-adherence and hypokalemia).
o
Initiate combination therapy:
§
Lisinopril 10 mg daily (ACEI:
addresses LVH, BP control, and potassium-sparing effects).
§
Amlodipine 5 mg daily (CCB:
synergistic BP-lowering, avoids hypokalemia risk).
o
Potassium supplementation: KCl
20 mEq daily until recheck.
2.
Non-Pharmacologic Interventions:
o
Diet: DASH
diet counseling; limit sodium to <2,300 mg/day.
o
Exercise: Gradual
increase to 150 min/week of moderate activity.
o
Alcohol: Reduce
to ≤2 drinks/day.
o
Smoking Cessation: Refer
to quitline; discuss nicotine replacement.
3.
Monitoring:
o
1-week follow-up: BP
check, assess for ACEI-related cough/angioedema.
o
4-week follow-up:
§
BP, serum K⁺, creatinine, LDL, and
HbA1c.
§
ECG repeat in 6 months to assess LVH
progression.
Patient Education
·
Emphasize medication
adherence and risks of untreated hypertension.
·
Teach home BP monitoring (goal
<130/80 mmHg).
·
Counsel on diet/exercise tailored to
weight loss (5–10% target).
Rationale: Combination ACEI/CCB offers potent BP control, mitigates
hypokalemia, and addresses LVH. Lifestyle modifications target obesity and
ASCVD risk. Close monitoring ensures safety and efficacy.
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