HEART SPECIALISTS IN GANGAMMA CIRCLE BANGALORE
Assessment of patients with hypertension
A patient with definite or possible newly diagnosed hypertension needs at least a basic clinical
assessment to look for possible aetiology, severity and signs of complications.
Questioning should be directed towards the following areas.
1 Past history. Has hypertension been diagnosed before? What treatment was instituted? Why
was it stopped?
2 Secondary causes. Important questions relate to:
• a history of renal disease in the patient or his or her family, recurrent urinary tract infec-
tions, heavy analgesic use or conditions leading to renal disease (e.g. systemic lupus
• symptoms suggesting phaeochromocytoma (flushing, sweats, palpitations)
• symptoms suggesting sleep apnoea
• muscle weakness suggesting the hypokalaemia of hyperaldosteronism
• Cushing’s syndrome (weight gain, skin changes)
• family history of hypertension.
3 Aggravating factors:
• high salt intake
• high alcohol intake
• lack of exercise
• use of medications: NSAIDs, appetite suppressants, nasal decongestants, monoamine
oxidase inhibitors, ergotamine, cyclosporin, oestrogen-containing contraceptive pills
• other: use of cocaine, liquorice, amphetamines.
4 Target organ damage:
• stroke or transient ischaemic attack (TIA)
• angina, dyspnoea
• fatigue, oliguria
• visual disturbance
5 Coexisting risk factors:
• lipid levels, if known
• existing vascular disease
• family history of ischaemic heart disease.
6 Factors affecting choice of treatment:
• diabetes (problems with thiazides and beta-blockers)
• gout (problems with thiazides)
• asthma (problems with beta-blockers)
• heart failure (problems with verapamil, diltiazem, some beta-blockers, monoxidine)
• severe peripheral arterial disease (problems with beta-blockers)
• bradycardia or heart block (problems with beta-blockers, verapamil, diltiazem)
• renovascular disease (problems with ACE inhibitors, angiotensin receptor antagonists
• problems with previous anti-hypertensive agents
• likelihood of pregnancy (ACE inhibitors, diuretics and some calcium antagonists are
The physical examination should be undertaken with a view to establishing severity.
1 Measure the blood pressure.
2 Look for secondary causes.
• Check the appearance for Cushing’s syndrome (central obesity, striae, muscle wasting),
acromegaly, polycythaemia and uraemia.
• Undertake abdominal palpation for renal masses (polycystic kidneys), occasionally adrenal
mass, and auscultation for renal bruit (heard to the left or right of the mid-line above the
umbilicus, often into the flanks).
• Assess radiofemoral pulse delay and listen for mid