The physical examination is not complicated

The physical examination is not complicated. The blood pressure needs to be measured reasonably, not through a sweater, not when the patient is standing, not after the patient has just been rushed into the room because you are running 30 minutes late in your office.Two or more blood pressures using an appropriate size cuff, make sure that you measure it in the opposite arm, particularly important in older patient’s who might have arteriosclerosis. If the patient has arteriosclerosis and has blockage of say their left subclavian artery, so the blood pressure in their left arm is lower than the blood pressure in the right arm, and you measure only the blood pressure in the left arm, and let’s say it’s 140/90, and you forget to measure the blood pressure in the right arm which is 160/100, you have not done a good thing because, which blood pressure is the heart exposed to. Which blood pressure is the brain exposed to, it’s the higher blood pressure, so you use the blood pressure which is the higher blood pressure. You look for evidence of neck bruits, heart failure, a big thyroid gland which is a rare cause of hypertension, is the heart bit, which is not a good thing, abdomen bruits, enlarged kidneys and are there poor pulses suggesting end organ disease. Again, the history and the exam are designed to answer three questions, primary secondary hypertension, end organ disease, and other cardiovascular risk factors. All of those questions ought to be answered by the time you finish with this list. A simple urinalysis to look for kidney disease, a serum potassium to screen for rare endocrine disease, increased aldosterone secretion but it also serves as an important baseline measurement because we are going to be giving most patient’s with stage I hypertension who need therapy diuretics, a serum sodium, glucose to look for other cardiovascular risk factors, serum creatinine to look for kidney function. Serum sodium is another baseline function because sometimes diuretics will cause hyponatremia. Cholesterol is to look for other risk factors, JNC recommends a complete blood count on all patient’s with chronic hypertension, I don’t know why. I can think of no good reason to do that.

The 12-lead electrocardiogram is to look for left ventricular hypertrophy or on rare occasions, evidence of a myocardial infarction that was not picked up in the history, a chest x-ray is not indicated. It is a terrible test for heart disease and unless the patient has symptoms, you need not do it. So the list is relatively small, again, focused on looking for end organ disease, secondary hypertension. If you decide that the patient has sustained elevations of their blood pressure, and after the appropriate focused history, exam and laboratory tests tell you as it will the vast majority of the time, that the patient has essential or primary or, yes you have elevated blood pressure and we have to idea why, then you have to start thinking about what you’re going to do about it. Here are the things you should start to do about it in every patient, no matter what the level of their blood pressure is. Some of these things are very difficult to do, I would suggest that if you don’t do them, then you are not doing a good thing for the patient and you are certainly not meeting reasonable standard of care, so you have to at least try to do most of these things. If somebody is grossly overweight, that is a major contributor to high blood pressure and it is reasonable to either counsel them or send them to somebody who can counsel them. That almost always involves increase in physical activity which is, in the vast majority of patient’s a very good thing for all sorts of reasons in addition to their hypertension.

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