Hypertension Review OSCE - White Coat Hypertension | Free OSCE Practice

Case Overview

Age/Sex: 19-year-old female
Occupation: University student (undergraduate)
Setting: Student health centre, presenting for routine check during exam period
Chief complaint: blood pressure check

Patient Script

Who I Am

I'm 19, a second-year university student, staying in halls and coming in between revision sessions.

What Brings Me In

I had my blood pressure taken at the campus clinic last week and it was high, so I wanted to get it checked again.

My Story

I first had my blood pressure taken at the campus health clinic last Friday and it was reported as about 150 over 95. I felt a bit worried so I used my aunt's blood pressure monitor at home on Saturday morning and it read 118 over 72, and I got a similar result the next morning. I've been really stressed because of exam revision for the past three weeks. I get occasional headaches when I'm studying for long periods, and sometimes my heart feels like it's racing, especially when I come into the clinic or before presentations. I started a combined oral contraceptive pill about six months ago. I drink a lot of coffee while revising—maybe two to three strong coffees a day—and had an energy drink two days ago. I don't smoke. I had one nosebleed last winter following a bad cold, but that's been fine since.

My Medical Background

Past medical history: none significant
Medications: combined oral contraceptive pill (started 6 months ago)
Allergies: none known
Social: drinks caffeine regularly (2-3 coffees/day), had 1 energy drink in last 48 hours, occasional alcohol on weekends, lives in halls, under high exam stress
Family history: mother has borderline high blood pressure in her 40s; father healthy

What I Think & Worry About

I think the high number at the clinic might mean I have high blood pressure.
I'm worried this could mean I need lifelong tablets or that it could affect my ability to continue at university.
I also worry the pill might be causing it.

If You Ask Me About Other Symptoms...

Headache: I get mild headaches during long study sessions, usually relieved by a break or coffee
Palpitations: yes, I notice my heart racing when I'm anxious or in clinics
Dizziness/syncope: none
Chest pain: none
Breathlessness: none
Visual changes/blurring: none
Urine changes: none

Clinical Summary

Examination

General: alert, mildly anxious appearance
Weight/Height: 60 kg, 165 cm (BMI 22.0 kg/m2)
Temperature: 36.8°C
Cardiovascular: heart sounds normal, no murmurs
Peripheral pulses: present and equal bilaterally
Neck: no thyromegaly, no jugular venous distension
Abdomen: soft, no masses, no renal bruits
Fundoscopy: no papilledema, no hypertensive retinopathy
Extremities: no peripheral oedema
Blood pressure (right arm, seated): 1st reading 148/94 mmHg, HR 98 bpm
Blood pressure (after 5 minutes rest, seated, right arm): 142/88 mmHg, HR 86 bpm
Blood pressure (standing at 1 minute): 120/76 mmHg, HR 84 bpm

Investigations

Office BP: 148/94 mmHg (initial); 142/88 mmHg (repeat) (interpreted as elevated in clinic)
Home BP: 118/72 mmHg (two morning readings on separate days) (interpreted as normal)
24-hour ambulatory BP monitoring (ABPM): mean daytime 121/76 mmHg, mean 24-hour 118/74 mmHg (interpreted as normotensive)
ECG: sinus rhythm, rate 86 bpm, no ischemic changes or LVH
Serum electrolytes: Na 139 mmol/L, K 4.1 mmol/L (normal)
Creatinine: 68 µmol/L (normal)
Urinalysis: no protein, no haematuria
Fasting glucose: 4.9 mmol/L (normal)
TSH: 2.0 mIU/L (normal)
Pregnancy test: negative

Diagnosis

Primary: White coat hypertension
- Evidence: elevated clinic blood pressure readings (148/94, 142/88) with normal home BP and ABPM (mean daytime 121/76 and 24-hr mean 118/74), young anxious patient situationally nervous in clinic, no end-organ damage and normal renal/function tests.
Differentials:
- Sustained hypertension: less likely given normal ABPM and home readings and lack of end-organ signs/labs.
- Anxiety-related transient BP spikes/panic: overlapping with white coat phenomenon; presence of exam-related anxiety and palpitations supports contribution of anxiety to BP elevations.
- Secondary hypertension (e.g., renal, endocrine): unlikely given normal electrolytes, creatinine, TSH, urinalysis and lack of suggestive signs.

Management

Immediate:
- Do not start antihypertensive medication at this time.
- Arrange or confirm 24-hour ABPM to document out-of-office BP (if not already done) or provide validated home BP monitor and instruct correct technique (seated, back supported, arm at heart level, rest 5 minutes, two measurements morning and evening for 7 days).
- Reassure patient about benign nature of white coat effect if ABPM/home readings confirm normotension.
Address contributing factors:
- Advise reduction of excessive caffeine and avoid energy drinks during exam period.
- Discuss stress management: short-term strategies (breathing techniques, breaks during revision), consider referral to university counselling if anxiety affecting daily function.
- Review combined oral contraceptive pill if clinic BP remains elevated on repeat testing; consider alternatives if persistent hypertension develops.
Follow-up:
- If ABPM/home BP normal: lifestyle advice and repeat BP assessment in 6-12 months or earlier if symptoms change.
- If ABPM/home BP elevated: initiate evaluation for sustained hypertension and consider starting therapy based on current guidelines.

Key Learning Points

Out-of-office blood pressure measurement (home BP or ABPM) is essential to distinguish white coat hypertension from sustained hypertension and avoid unnecessary treatment.
Young anxious patients commonly exhibit white coat effect; take multiple clinic readings after rest and consider the clinical context (exam stress, caffeine, OCP use) before diagnosing hypertension.
Management of confirmed white coat hypertension focuses on reassurance, monitoring, and addressing modifiable contributors (stress, caffeine); do not start antihypertensive drugs solely on elevated clinic readings without corroborating out-of-office measurements.