Hypertension Review OSCE - New Hypertension Diagnosis

Case Overview

• Age/Sex: 56-year-old male
• Occupation: Office administrator (sedentary job)
• Setting: Primary care clinic, booked for blood pressure check after family advice
• Chief complaint: "I just want a blood pressure check"

Patient Script

Who I Am

I'm a 56-year-old office worker who sits at a desk most of the day and has been a smoker for years.

What Brings Me In

I came because my cousin had a stroke last month and told me to check my blood pressure — I got worried and want it checked today.

My Story

I've been feeling a bit more tired for the last 3 months, and I noticed some headaches over the past 2 weeks, mostly in the mornings. Last week I checked my blood pressure at the pharmacy and it read about 165/100, so I booked this appointment. I had one episode of a tight feeling across my chest about a month ago when I was rushing up some stairs at work, but it went away after a few minutes and I haven't had it since. I sometimes take ibuprofen for a sore back and I have a couple of beers most evenings. I smoke about a pack a day and I don't exercise much — mostly just commute and sit at my desk.

My Medical Background

• Past medical history: No diagnosed chronic illnesses that I know of
• Current medications: Occasionally ibuprofen 400 mg for back pain (a few times a week)
• Allergies: None known
• Social history: Smokes ~20 cigarettes/day; drinks ~1–2 beers nightly; sedentary job; lives with wife
• Family history: Father had a stroke at age 70; mother has type 2 diabetes

What I Think & Worry About

• I’m worried this could be something serious like a stroke or heart problem because my cousin had a stroke.
• I don’t like the idea of being on tablets for the rest of my life if that’s what it comes to.
• I’m concerned about work — I can’t afford to be unwell or off work.

If You Ask Me About Other Symptoms...

• Chest pain: Occasionally had that one tightness on stairs last month; not ongoing and not crushing.
• Shortness of breath: None at rest; a little breathless climbing several flights of stairs, but that’s normal for me.
• Palpitations: No
• Dizziness/syncope: No fainting, no blackout episodes
• Visual symptoms: No loss of vision or flashing lights
• Urinary symptoms: No changes in urine or pain on passing urine
• Sleep: I snore sometimes and wake feeling unrefreshed; my wife says I snore loudly some nights
• Medications/adherence: I don’t take any regular medicines besides the occasional ibuprofen

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Clinical Summary

Examination

• Blood pressure (right arm, sitting): 162/96 mmHg
• Blood pressure (left arm, sitting): 160/94 mmHg
• Heart rate: 84 beats/min, regular
• Respiratory rate: 14/min
• Temperature: 36.7 °C
• BMI: 29 kg/m2 (overweight)
• Waist circumference: 102 cm
• Cardiorespiratory exam: Heart sounds normal, no murmurs; lungs clear to auscultation
• Peripheral pulses: Palpable and equal bilaterally; no peripheral edema
• Fundoscopy: No papilledema; mild arteriolar narrowing
• Neck: No carotid bruits

Investigations

• Repeat clinic BP after 5 minutes seated: 160/95 mmHg (consistent with initial reading)
• Home BP reading (patient-reported, 1 reading last week): 165/100 mmHg (pharmacy device)
• Urinalysis: Trace protein on dipstick (urine albumin/creatinine ratio: 4.5 mg/mmol — microalbuminuria)
• Serum electrolytes and renal function: Na 140 mmol/L; K 4.2 mmol/L; Creatinine 95 µmol/L; eGFR ~75 mL/min/1.73 m2 (within acceptable range)
• Fasting glucose: 6.1 mmol/L (impaired fasting glucose)
• Lipid profile: Total cholesterol 6.2 mmol/L; LDL 3.8 mmol/L; HDL 1.0 mmol/L; Triglycerides 1.9 mmol/L
• 12-lead ECG: Sinus rhythm 84 bpm; no acute ischemic changes; no definite LVH criteria

Diagnosis

• Primary diagnosis: New diagnosis of hypertension (grade 2 / stage 2) — supported by repeated clinic readings around 160–165/94–100 mmHg, a pharmacy/home reading in the same range, and presence of microalbuminuria indicating target-organ effect.

• Differential diagnoses and reasoning:

  • White coat hypertension: Less likely given elevated home/pharmacy reading reported and repeat clinic readings remain high.
  • Secondary hypertension due to medication (NSAID use): Possible contributor — patient uses ibuprofen intermittently; evaluate and advise avoidance if possible.
  • Obstructive sleep apnea (OSA): Possible contributor given obesity, snoring, daytime tiredness; consider screening.
  • Renovascular or endocrine causes (e.g., hyperaldosteronism): Less likely given normal electrolytes and renal function, but consider if young onset or resistant hypertension.

Management

• Confirm diagnosis: Arrange 24-hour ambulatory blood pressure monitoring (or a validated schedule of twice-daily home BP measurements over 7 days) to confirm hypertension severity.
• Cardiovascular risk modification:
  • Advise smoking cessation and offer referral to smoking cessation services.
  • Counsel on diet (reduce salt, adopt DASH-style diet), weight loss, and increase physical activity (aim for 150 min/week moderate exercise as tolerated).
  • Advise limiting alcohol and avoiding regular NSAID use; discuss alternative pain strategies.
• Pharmacologic therapy:
  • Given clinic BPs consistently ≥160/100 mmHg and evidence of microalbuminuria, start antihypertensive therapy rather than waiting: consider an ACE inhibitor (e.g., ramipril) as first-line (check renal function and potassium 1–2 weeks after initiation/change).
  • Consider starting a statin (e.g., atorvastatin) for primary prevention given age and lipid profile after assessing overall cardiovascular risk.
• Baseline and monitoring tests before/after initiating therapy:
  • Repeat U&E and creatinine, electrolytes within 1–2 weeks of ACE inhibitor initiation.
  • Annual monitoring of ACR, lipids, fasting glucose/HbA1c.
• Address possible OSA: screen with STOP-Bang or refer for sleep assessment if high suspicion.
• Follow-up: review BP and side effects 2–4 weeks after starting therapy; adjust doses or add agents as needed aiming for individualized BP targets.

Key Learning Points

• Confirm elevated clinic blood pressure with ambulatory or structured home measurements before labeling chronic hypertension, but treat promptly when readings are consistently in the grade 2 range or when target-organ damage is present.

• Assess for and address reversible contributors (smoking, alcohol, NSAIDs, obesity, sleep-disordered breathing) alongside pharmacologic therapy.

• Baseline investigations (U&E, ACR, lipids, glucose, ECG) are important to detect end-organ effects and guide choice and safety of antihypertensive therapy.