IM8.{8,10-12,16} | Hypertension Clinical Evaluation — Summary & Reflection

KEY TAKEAWAYS

Hypertension clinical evaluation — key framework:

• Structured history (IM8.8): 8 domains — duration/levels, symptoms (TOD + secondary cause clues), comorbidities, lifestyle (sodium, alcohol, exercise, sleep), family history, psychosocial/environmental, dietary assessment, previous/concomitant therapy. Secondary cause red flags: young age, resistant HTN, spontaneous hypokalaemia, episodic symptoms, Cushingoid features, pulse disparity.

• Differential diagnosis (IM8.10): Primary HTN is the default (90–95%); prioritise secondary cause workup when clinical features suggest one. Use the compartment-aetiology framework: renovascular (bruit, young, resistant), primary aldosteronism (hypokalaemia), phaeochromocytoma (episodic triad), Cushing (striae, proximal myopathy), coarctation (radio-femoral delay), OSA (snoring, daytime somnolence), drug-induced (OCP, NSAIDs, steroids).

• Mandatory investigations (IM8.11, IM8.12): CBC, urine routine (ACR for microalbuminuria), BUN/creatinine/eGFR, electrolytes (K+ key), uric acid, fasting glucose/HbA1c, fasting lipids, ECG.

• ECG (IM8.16): LVH by Sokolow-Lyon (S-V1 + R-V5/V6 ≥35 mm), Cornell (R-aVL + S-V3 >28/20 mm); strain pattern = lateral ST depression + T-wave inversion in LVH; P-mitrale = LA enlargement; AF = commonest arrhythmia; LBBB = new + chest pain → STEMI equivalent. ECG sensitivity for LVH is ~50% — echocardiography is gold standard.

• Cardiovascular risk stratification: BP level + risk factors + comorbidities + TOD → low/moderate/high/very high → drives treatment threshold and target.

• Special situations: Bilateral renal artery stenosis → ACE inhibitor/ARB contraindicated; phaeochromocytoma → alpha-block BEFORE beta-block; pregnancy → methyldopa, labetalol, nifedipine only (ACE inhibitor/ARB contraindicated); elderly → check orthostatic hypotension.

REFLECT

Think about the two patients in the opening hook — Suresh with obesity-driven hypertension and possible obstructive sleep apnoea, and Kavitha with hypertension in pregnancy. Both need a blood pressure recorded, but the history you would take, the examination findings you would specifically seek, the investigations you would order, and the urgency of your response differ entirely. Now extend this to your own clinical environment: in a busy outpatient department where 30 patients are waiting, what is the minimum history and examination that you would perform for a 55-year-old man presenting with newly discovered BP 152/94 mmHg and no symptoms? Which components could you safely defer to a follow-up visit, and which must you address today? Developing this sense of clinical proportionality — knowing what is essential now versus what can be safely deferred — is what separates a competent clinician from one who either over-investigates or misses critical findings.