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Chapter 3
CLINICAL AND LABORATORY EVALUATION
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Hypertension, unless complicated, is asymptomatic
disease. Diagnosis depends upon accurate and repeated measurements
of blood pressure.
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The objective of clinical and laboratory evaluation
is to establish the presence of hypertension, identify other cardiovascular
risk factors, diagnose target organ damage, and detect secondary forms
of hypertension.
Aim of Evaluation
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Establishment of the diagnosis of hypertension.
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Assessment of global cardiovascular risk.
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Evaluation of target organ damage.
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Diagnosis of secondary causes of hypertension.
Value of Early Recognition of Hypertension
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Blood pressure
level is linearly and continuously related to the risk of cardiovascular
diseases and stroke.
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Target
organ damage occurs early in the hypertensive process.
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Hypertension
commonly occurs in association with other risk factors which interact
synergistically to multiply cardiovascular risk.
Medical History
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In most patients, uncomplicated hypertension
causes no significant symptoms.
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Physician should inquire specifically about:
1. Previous levels of high blood pressure with and without treatment.
2. Symptoms of target organ damage.
3. Symptoms suggestive of secondary forms of hypertension (see chapter
4).
4. Current drug intake (e.g., contraceptive pills, non-steroid anti-inflammatory
agents, etc.) (see chapter 5).
5. Comorbid conditions (diabetes, bronchial asthma, gout, migraine, depression,
sexual dysfunction, etc.).
6. Family history of diabetes, coronary artery disease, stroke or renal
disease.
7. Life style factors: salt and fat intake, smoking, physical activity
and alcohol consumption.
Clinical Examination
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Establish
the diagnosis of high blood pressure by using proper measurement procedure
(see chapter 2).
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Peripheral
pulses should be palpated. Document that the femoral pulse are not
delayed beyond the radial pulse.
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Listen
for neck bruits.
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Cardiac
examination for left ventricular enlargement, third heart sound, loud
aortic closure sound and ejection murmur over the aortic area. Carefully
look for aortic incompetence murmur.
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Abdominal
examination for renal enlargement, abdominal aortic aneurysm or bruits.
Abdominal bruits are more suggestive of renal artery stenosis when
they are lateralizing and continuous (systolic-diastolic).
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Chest examination
for evidence of obstructive airway disease.
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Neurologic
examination for level of consciousness, speech, motor power, lateralization
and peripheral neuropathy. Profound muscle weakness with intact sensory
function in a hypertensive patient should suggest primary aldosteronism.
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Optic fundi
should be examined whenever possible (and in all patients with severe
or resistant hypertension).
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Body weight
and height to assess body mass index (normal value < 25 kg/m2).
Waist circumference should be recorded whenever possible.
Laboratory Tests
The Standard-Optimal- Care
- Urine examination by dipstic and microscopic
examination of the sediment.
- Serum potassium.
- Serum creatinine.
- Fasting plasma glucose
- Hemoglobin.
- Serum uric acid.
- Lipid profile (twelve hours fasting serum total
cholesterol, HDL-C, LDL-C, and triglycerides).
- Standard 12-lead ECG.
The Minimum Evaluation Care
- Urine examination by dipstic.
- Electrocardiogram (if possible).
- Fasting plasma glucose (if possible).
Optional Tests
- When secondary forms of hypertension are suspected.
- To determine the significance of borderline
hypertension by screening for target organ involvement.
- When symptoms are suggestive of target organ
damage.
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Extensive investigations include echocardiography,
abdominal and peripheral ultrasonographic examination, testing for
microalbuminuria, ambulatory blood pressure recording and specific
(goal-oriented testing) for suspected secondary hypertension (see
chapter 5) or a hypertensive complication (see chapter 9).
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