Hypertension Review OSCE - Resistant Hypertension | Free OSCE Practice

Case Overview

Age/Sex: 74-year-old male
Occupation: Retired engineer
Setting: Primary care clinic appointment requested for routine blood pressure check
Chief complaint: "I came in for my blood pressure check"

Patient Script

Who I Am

I am a 74-year-old retired engineer who lives alone and looks after myself.

What Brings Me In

My blood pressure has been high for a while and the nurse told me to come back so the doctor can check it.

My Story

I was first told my blood pressure was a bit high about 3 years ago and I was started on tablets. I've been on three different blood pressure pills for about 18 months now but my readings at the surgery and at home have still been high. For the past 3 months the nurse says it's been consistently high, even though I take my tablets every day. I check it at home every few days and usually record numbers like 160–180 over 90–100. I get a mild headache in the mornings a few times a week, worse when I wake up, and I sometimes feel a bit dizzy if I stand up quickly, but that has not stopped me doing what I need to do.

I sleep poorly and my neighbour once said I snore loudly — I usually feel a bit tired during the day but I put that down to getting older. I have some knee pain and take an over-the-counter pain tablet now and then. I smoked in my younger years but stopped about 20 years ago, and I have a couple of beers most evenings. My son keeps telling me to cut down the salt but I like my food.

My Medical Background

Past medical history: hypertension diagnosed 3 years ago; osteoarthritis (knees)
Current medications: lisinopril 20 mg once daily, amlodipine 10 mg once daily, hydrochlorothiazide 25 mg once daily (all for ~18 months)
OTC/other: ibuprofen 400 mg occasionally for knee pain (a couple times a week); used a nasal decongestant spray briefly last winter
Allergies: none known
Social: lives alone, retired, drinks ~2 small beers nightly, independent with ADLs
Smoking: ex-smoker, 40 pack-year history, quit 20 years ago
Family: father had a stroke at age 70

What I Think & Worry About

I worry: "Am I going to have a stroke or heart attack because my blood pressure won't come down?"
I think: "Maybe this is just part of getting old — the tablets aren't working as well as they used to."
I worry: "I don't want to end up needing my family to look after me if something happens."

If You Ask Me About Other Symptoms...

Chest pain: "I sometimes get a tight feeling after a heavy meal but it settles with antacids — nothing like a crushing chest pain."
Breathlessness: "I get a bit out of breath climbing stairs compared with a few years ago, but I can still manage one flight slowly."
Fainting/syncope: "No fainting, just the odd lightheaded spell when I stand up quickly."
Leg swelling: "My ankles swell a little after a long day but it's not too bad."
Urinary or renal: "No change in how often I pee at night, maybe once sometimes twice; I pass urine normally."
Medication problems/side effects: "I sometimes forget an evening pill if I go out, but mostly I take them. I haven't had any dizzy spells since starting these tablets apart from the odd time standing up quickly."
Sleep: "I snore, and I feel tired during the day sometimes — I nap once in a while."

Clinical Summary

Examination

Sitting BP (right arm, automated, after 5 minutes rest): 172/98 mmHg
Repeat sitting BP (5 minutes later): 170/96 mmHg
Standing BP (after 1 minute): 158/88 mmHg (pulse rise 4 bpm) — no significant orthostatic hypotension
Heart rate: 78 beats per minute, regular
BMI: 31 kg/m2 (overweight/obese)
Cardiovascular: no added murmurs, peripheral pulses present and symmetrical
Lungs: clear to auscultation
Abdomen: non-tender, no renal bruits heard on careful auscultation
Extremities: mild pitting ankle edema
Neurological: no focal deficits
Fundoscopy: mild arteriolar narrowing, no papilloedema

Investigations

Clinic basic bloods: Na+ 139 mmol/L (normal), K+ 4.0 mmol/L (normal) — interpretation: no hypokalemia to suggest overt primary hyperaldosteronism but diuretics may mask abnormalities
Creatinine: 110 µmol/L, eGFR ~55 mL/min/1.73 m2 (stage 3a CKD) — interpretation: mild chronic kidney disease, could contribute to hypertension
Urine ACR: 4.0 mg/mmol (mild albuminuria) — interpretation: some renal involvement related to hypertension
ECG: left ventricular hypertrophy by voltage criteria (small QRS changes consistent with LVH) — interpretation: target-organ effect of long-standing hypertension
Home BP log: multiple entries over last month averaging ~165/94 mmHg — interpretation: concordant with clinic readings
Ambulatory blood pressure monitoring (24-hour ABPM): daytime mean 156/92 mmHg, night mean 140/82 mmHg — interpretation: confirms sustained hypertension (rules out white-coat hypertension)

Diagnosis

Primary diagnosis: Resistant hypertension
- Evidence: persistent clinic and ambulatory BP elevation (clinic 170–172/96–98 mmHg; ABPM daytime mean 156/92 mmHg) despite treatment with three antihypertensive agents including a diuretic (lisinopril + amlodipine + HCTZ). There is end-organ effect (LVH on ECG, mild CKD, mild albuminuria).
Differential diagnoses/considerations:
- Poor medication adherence/pseudo-resistance — patient reports good adherence but this must be assessed objectively (pharmacy refill review, pill counts) because it is a common cause of apparent resistance.
- White-coat hypertension — made less likely by ABPM showing sustained elevation.
- Secondary causes of hypertension:
  - Obstructive sleep apnea: suggested by snoring, daytime tiredness; common contributor to resistant hypertension.
  - Renovascular disease: possible given age and CKD, but no abdominal bruit and creatinine only mildly elevated; consider if BP is sudden-onset or progressive.
  - Primary hyperaldosteronism: less likely without hypokalemia but not excluded (diuretics can confound potassium).
  - Drug-induced elevation: intermittent NSAID use and past decongestant use can raise BP and should be reviewed.

Management

Confirm adherence objectively: discuss medication-taking, request pharmacy refill history, encourage patient to bring medications/boxes to next visit.
Lifestyle and medication review:
- Advise strict dietary sodium reduction, weight loss, and reduce alcohol intake.
- Stop OTC NSAIDs where possible and avoid decongestant sympathomimetics.
Confirm true resistance already done with ABPM; proceed with treatment escalation:
- Add a mineralocorticoid receptor antagonist (e.g., spironolactone 25 mg nocte) as the next step for resistant hypertension, with plan to check serum potassium and creatinine within 1–2 weeks and again after dose changes.
- Consider substitution of hydrochlorothiazide for chlorthalidone if more potent thiazide-like diuretic desired (discuss risks/benefits given age/renal function).
Evaluate for secondary causes:
- Arrange sleep study (overnight oximetry or polysomnography) for suspected obstructive sleep apnea and consider referral for CPAP if positive.
- Consider renal artery imaging (duplex ultrasound or CT/MR angiography) if clinical suspicion of renovascular disease increases (e.g., abrupt worsening, worsening renal function with ACE inhibitor, asymmetric kidneys).
- If hypokalemia or other features suspicious for primary aldosteronism develop, arrange plasma aldosterone/renin ratio (after appropriate medication adjustments if possible) or refer to specialist.
Monitor and follow-up:
- Repeat BP checks and review home BP log in 2–4 weeks after medication change.
- Recheck renal function and electrolytes 1–2 weeks after starting spironolactone and periodically thereafter.
- Consider referral to hypertension clinic/renal specialist if uncontrolled on four agents or if secondary cause suspected.

Key Learning Points

Confirm true resistant hypertension before labeling: ensure adherence, obtain home BP readings or ABPM to exclude white-coat effect.
In patients uncontrolled on three agents including a diuretic, adding a mineralocorticoid receptor antagonist (e.g., spironolactone) is an evidence-based next step, with close monitoring of potassium and renal function.
Always review concurrent medications and lifestyle factors (NSAIDs, decongestants, high salt intake, alcohol, obstructive sleep apnea) and screen for common secondary causes when hypertension is resistant.