Simple assessments and investigations involved in Hypertension

A strong history of hypertension, along with the reported finding of intermittent pressure elevation in the past, favors the diagnosis of essential hypertension.

Secondary hypertension often develops before the age of 35 or after 55. The history of use of adrenal steroids or estrogens is of obvious significance.

A history of repeated urinary tract infections suggests chronic pyelonephritis, although this condition may occur in the absence of symptoms, nocturia and polydispia suggest renal or endocrine disease while trauma to either flank or an episode of acute flank pain may be a clue to the presence of renal injury.

A history of weight gain is compatible with cusing’s syndrome and weight loss with pheochromocytoma. A number of aspects of the history aid in stages.

These include angina pectoris and symptoms of cerebrovascular insufficiency of congestive heart failure and / or of peripheral vascular insufficiency.

Other risk factors that should be elicited include cigarette smoking, diabetes mellitus, libido disorders and a family history of early deaths due to cardiovascular disease.

Finally aspects of the patient’s lifestyle which could contribute to the hypertension or affect its treatment should be assessed including diet, physical activity, family status, work and educational level.

Physical examination: The physical examination starts with the patient’s general appearance. For instance, are the round face and trunkal obesity of Cushing’s syndrome present?

Is muscular development in the upper extremities out of proportion to that in the lower extremities suggesting coarcation of the aorta? The next step is to compare the blood pressures and pulses in both upper extremities and in the supine and standing positions.

A rise in diastolic pressure when the patient goes from the supine to the standing position is most compatible with essential hypertension, a fall in the absence of antihypertensive medications suggest secondary forms of hypertension.

The patient’s height and weight should be recorded. Detailed examination of the ocular fundi is mandatory since funduscopic findings provide one of the best indications of the duration of hypertension and of prognosis.

Palpation and auscultation of the carotid arteries for evidence of stenosis or occlusion are important, narrowing of a carotid artery may be a manifestation of hypertensive vascular disease and it also may be a clued to the presence of a renal arterial lesion, since these two lesions may occur together.

In examination of the heart and lungs, one should search for evidence of left ventricular hypertrophy and cardiac decomposition. Chest examination also includes a search for extra cardiac murmurs and palpable collateral vessels that may result from coarctation of the aorta.

The most important part of the abdominal examination is auscultation for bruits originating in stenotic renal arteries. Bruits due to renal arterial narrowing nearly always have a diastolic component or may be continuous and are best heart just to the right or left of the midline above the umbilicus or in the flanks.

They are present in many patients with renal artery stenosis due to fibrous dysplasia and in 40 to 50 percent of those with functionally significant stenosis due to arteriosclerosis.

The abdomen also should be palpated for abdominal aneurysm and for the enlarged kidneys of polycystic renal disease. The femoral pulses must be carefully felt, and if they are decreased and delayed in comparison with the radial pulse, the blood pressure in the lower extremities must be measured.

Even if the femoral pulse is normal to palpation, arterial pressure in the lower extremities should be recorded at least once in patients in whom hypertension is discovered before the age of 30 years.

Finally, examination of the extremities for edema and a search for evidence of a previous cerebrovascular accident and other intracranial anthology should be performed.

Laboratory investigation: Controversy exists as to what laboratory studies should be performed in patients presenting with hypertension. In general, the disagreement resides in how extensively to evaluate the patient for secondary forms of hypertension.

In general, the disagreement resides in how extensively to evaluate the patient for secondary forms of hypertension or subsets essential hypertension. Other blood chemistries also may be useful, particularly since they often can be ordered as a battery of automated tests at minimal cost to the patient.

For example, a blood glucose determination is helpful both because diabetes mellitus may be associated with accelerated arteriosclerosis, renal vascular disease and diabetic nephropathy in patients with hypertension and because primary aldosteronism.

The possibility of hypocalcaemia also may be investigated. Serum uric acid determination is useful because of the increased incidence of hyperuricemia in patients with renal and essential hypertension and because as with blood glucose.

The level subsequently may be raised by treatment with diuretics. Serum cholesterol, HDL cholesterol and triglycerides may be measured to identify other factors, which predispose to the development of arteriosclerosis.

Clinical assessments and investigations involved in Hypertension