1. HTN Cases
Pharmacotherapy - 1

2. Case 1
T.J. is a 45-year-old white woman with a history of type 2 diabetes mellitus with macroalbuminuria treated with glyburide 5 mg/day. She presents to the clinic for a routine follow-up of her diabetes. Her vital signs today include BP (average of two readings) 138/88 mm Hg and HR 70 beats/minute. Her laboratory results are as follows: Na 140 mEq/L, K 4.0 mEq/L, chloride 102 mEq/L, bicarbonate 28 mEq/L, BUN 14 mg/dL, and SCr 1.8 mg/dL. Of note, at her last visit, her BP was 136/85 mm Hg.
BUN 14 mg/dL ( 2.5-8) , and SCr 1.8 mg/dL

3. 1- Which is best for managing her hypertension at this time. A
1- Which is best for managing her hypertension at this time? A. Begin lifestyle modifications. B. Begin lifestyle modifications and add amlodipine 5 mg/day. C. Begin lifestyle modifications and add lisinopril 2.5 mg/day. D. Begin lifestyle modifications and add atenolol 25 mg/day.

7. Answer: C The BP goal in individuals with diabetes mellitus or chronic renal dysfunction is less than 130/80 mm Hg. Despite the categorization of prehypertension, the presence of diabetes warrants immediate therapy to attain a more aggressive goal BP of less than 130/80 mm Hg than in patients without diabetes. 

8. The presence of diabetes presents a compelling reason to include an ACE inhibitor in the absence of any contraindication. Lisinopril initiated at a low dose of 2.5 mg/day is appropriate given this patient's level of renal dysfunction and mildly elevated BP (Answer C).
Although amlodipine (Answer B) could get the patient to her goal BP, this agent might not be as renal-protective as an ACE inhibitor.

9. Likewise, no compelling indication is present for using a β-blocker in this patient; therefore, an atenolol-based regimen is less desirable than the ACE inhibitor regimen (Answer D). In all situations, lifestyle modifications should be emphasized to this patient (Answer A); however, additional drug therapy is warranted for her.

10. Case 2
DW is a 50-year-old African man being discharged from the hospital after an acute MI. His medical history is significant for hypertension. He was taking hydrochlorothiazide 25 mg/day before hospitalization.
An echocardiogram before discharge shows an LVEF of more than 60%. His vital signs include BP 150/94 mm Hg and HR 80 beats/minute.
* SOAP this case

11. Which is the best approach for managing his hypertension?
A. Discontinue hydrochlorothiazide and add diltiazem.
B. Continue hydrochlorothiazide and add metoprolol.
C. Discontinue hydrochlorothiazide and add losartan.
D. Continue hydrochlorothiazide and add losartan.

12. Case 3
You are seeing a 60-year-old man for the first time. He has untreated hypertension (168/106 mm Hg and blood pressure has been elevated on at least 3 occasions). There is currently no evidence of target organ dysfunction (heart, neurological, or eyegrounds).
From a therapeutic perspective, what is the best initial approach?
A. Initiate treatment with 25 mg of hydrochlorothiazide.
B. Consider initiating treatment with a 2-agent combination pill.
C. Delay pharmacologic intervention and treat with salt restriction.

13. Case 4
TA is a 58 year old male. He reports to the emergency room after being seen at the his primary care physician's clinic. His blood pressure upon entering the emergency room is 200/130 mm Hg and he has shortness of breath (SOB) with a headache. He has a past medical history of hypertension x 5 years. He denies smoking and illicit drug use. He rarely drinks alcohol. His medications are the following: Lisinopril 20 mg QD, HCTZ 25 mg QD. His labs are all within normal limits.

14. How would you characterize his hypertension and what is the goal blood pressure?
Hypertensive Urgency; < 160/100 mmHg in hours
Hypertensive Urgency; < 120/80 mmHg in minutes
Hypertensive Emergency; Reduce mean arterial pressure to 120 mmHg in 2 hours
Hypertensive Emergency; < 160/100 mmHg over 2-6 hours

15. A patient is diagnosed with primary hypertension
A patient is diagnosed with primary hypertension. When taking the patient’s history, the healthcare provider anticipates the patient will report which of the following?
“I have not noticed any significant changes in my health.”
Sometimes I get pain in my lower legs when I take my daily walk.”
“Every once in awhile I wake up at night covered in sweat.”
“I’m starting to get out of breath when I go up a flight of stairs.”

16. The results of an adult patient’s blood pressure screening on three occasions are: 120/80 mmHg, 130/76 mmHg, and 118/86 mmHg. How will the healthcare provider interpret this information?
Normal
Prehypertensive
Stage 1
Stage 2

17. A patient is prescribed a thiazide diuretic for the treatment of hypertension. When teaching the patient about the medication, which of the following will the healthcare provider include?
“Take this medication each day with a large glass of water after your evening meal.”
“I’ll teach you how to take your radial pulse before taking the medication.”
“Stop taking this medication if you notice changes in how much you urinate.”
“Be sure to include a number of foods that are rich in potassium in your diet.”

18. A patient is prescribed a calcium channel blocker to treat primary hypertension. When teaching the patient about the medication, which of these foods will the healthcare provider advise the patient to avoid?
Eggs
Bananas
Oranges
Grapefruit

19. A patient tells the healthcare provider, “I stopped taking my medication because it kept me up at night with a dry cough.” When reviewing the patient’s medical record, which of these antihypertensive medications will the healthcare provider identify as the likely cause of this patient’s report?
A. Beta blocker
B. Calcium channel blocker
C. Loop diuretic
D. Angiotensin-converting enzyme (ACE) inhibitor

20. Thank you