CASE STUDY ANALYSIS: HYPERTENSION
Abigail R. Harris
School of Nursing, Liberty University
Author Note:
Abigail R. Harris
I have no known conflict of interest to disclose
Correspondence concerning this paper should be addressed to Abigail R. Harris
Email: arharris11@liberty.edu
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Case Study Analysis: Hypertension
CASE STUDY ANALYSIS: HYPERTENSION
Case Study Analysis: Hypertension
CC: “My daughter is a CNA and says I need to see a doctor for a check-up”.
HPI: GKC is a 61 YO Caucasian male who presents to his new family practice
physician for
evaluation of his medical problems. He has no particular
complaints today. He states he
occasionally has problems with sinus allergies and
“picked up some Sudafed at Wal-Mart.”
PMH: Hypertension for approximately 8 yrs.
No history of CAD or DM.
FH: Father died of acute MI at age 73; mother died of lung cancer at age 69; brother
(age 68) has HTN and hyperlipidemia; and younger sister (age 55) has no known
medical problems.
SH: He has been married for 39 years and has one son and daughter (in their
20s) who are
healthy. He quit smoking a pipe about 6 years ago. He states
his alcohol intake is 6–8
drinks/week. He is retired and enjoys walking
around the neighborhood with his wife 1–2
times per week. He does not
pay attention to what he eats. He enjoys a “good ole Southern diet” and
adds salt to his food. He denies ever being placed on any diet due to his
medical conditions.
Meds: Hydrochlorothiazide/triamterene 25/37.5mg QD x 8 years
Sudafed 60mg Q6 hours PRN sinus drainage
Aleve 1 to 2 tablets QD PRN joint pain
All: NKDA
PE: Gen- A&Ox3, obese Caucasian man in NAD
VS- Average BP 155/86, HR 55, RR 16, Ht. 6’0”, Wt. 255 lbs.
HEENT- TM’s clear throughout and no drainage, EOMI; funduscopy shows
arteriolar narrowing
Lungs- few basilar crackles; no wheezing
Heart- RRR (slow), normal S1 and S2
ABD- Soft and ND; mildly tender in suprapubic area, no masses, bruits
Rectal/GU- Prostate 1+ (enlarged); prostate benign. Heme (-) stool
Ext- No clubbing, cyanosis, or edema
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CASE STUDY ANALYSIS: HYPERTENSION
Lab Results: Na- 136 mEq/ml K- 3.8 mEq/ml
Cl- 98 mEq/ml HCO3- 29 mEq/ml
BUN- 22 mg/dl Glucose- 181 mg/dl
HgbA1c- 8.5% TCHOL- 262 mg/dl
LDL- 1800 mg/dl TGs- 275 mg/dl
HDL- 35 mg/dl AST- 32 U/I
ALT- 30 U/I Alk Phos- 38 U/I
SCr- 1.0 mg/dl
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CASE STUDY ANALYSIS: HYPERTENSION
I. AP Notes
A. Present the Problem:
GKC comes into the office today with no specific complaints or issues, but his daughter
did want him to come be seen due to his blood pressure and weight. According to his
physical exam the patient has abnormal VS, abnormal LS, pain in his suprapubic region
with palpation, ocular changes, as well as some abnormal laboratory blood values. Due to
these findings, his medication regimen will have to be adjusted and medications will need
to be added to his daily schedule. Based off of the physical exam and lab values, the
patient has diagnoses of: uncontrolled hypertension, hypertensive retinopathy,
hyperlipidemia, hyperglycemia with probable diagnosis of DM type II, benign prostate
hypertrophy, and a possible UTI or urinary retention secondary to the prostate
hypertrophy.
B. Risk Factors
oAge
oObesity- BMI 34.6
oExcess salt added to diet
oOnly walks 1-2 times a week around the neighborhood for exercise
oHx of smoking (quit 6 years ago)
oAlcohol intake (6-8 drinks per week)
oComorbidities- uncontrolled hypertension
oUsing NSAIDs and decongestants with a diagnosis of hypertension
oFamily hx of CVD- Father died of an acute MI
oHyperlipidemia
oHyperglycemia
oIncreased kidney function (BUN & Creatinine)
C. Assessment
1. Evaluation:
GKC is a 61-year-old Caucasian male who came to his PCP after his
daughter, who is a CNA, wanted him to come in for evaluation and a physical. He
has a past medical history of hypertension, sinus allergies, and joint pain. When
asked how the patient is feeling he states he has no complaints today but upon
assessment was found to be hypertensive at 155/86, and bradycardic with a heart
rate of 55bpm. Unsure of how compliant GKC is with his medications, he has
been on the same blood pressure medication, Hydrochlorothiazide/triamterene, for
the past 8 years. During his exam, the patient was also noted to have mild
hypertensive retinopathy indicated by his retinal arteriolar narrowing, most likely
due to vasospasm and noncompliance with his blood pressure medications (Hua et
al., 2021). When listening to his lungs, crackles were heard in the base of his
lungs indicating a possible fluid overload (pulmonary edema) or possible
infectious process (Chamarthy, Kandathil, & Kalva, 2018). GKC was also noted
to have suprapubic pain with abdominal palpation which could be related to
urinary retention due to his enlarged prostate (benign prostatic hypertrophy) and is
not currently being treated for this with any medications. Looking at his blood
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CASE STUDY ANALYSIS: HYPERTENSION
work, his labs show he has an elevated fasting glucose level of 181 mg/dL and an
HgbA1c of 8.5%, concluding he has Diabetes Type II. It was also noted on his
labs that his total cholesterol is elevated at 262 mg/dL, triglycerides are 275
mg/dL, an HDL of 35 mg/dL, and an LDL of 180 mg/dL. All of those lab results
indicate he has dyslipidemia which can increase his risk for atherosclerosis, heart
attack, stroke, and other cardiovascular diseases (Cicero, Landolfo, Ventura, &
Borghi, 2019). His labs also show his BUN and Creatinine are both elevated at 22
mg/dL and 1.0 mg/dL respectively. GKC is also noted to have a Sodium level of
136 mg/dL and a chloride level of 98 mg/dL, which are both lower than they
should be. The patient states he has a family history of cardiovascular disease as
his father died of an acute MI, his mother died of lung cancer, and his brother is
alive but also has hypertension. Socially the patient drinks 6-8 alcoholic
beverages per week, adds excess salt to his food, and takes walks 1-2 per week
with his wife around the neighborhood.
Home Medications:
Hydrochlorothiazide/triamterene 25/37.5mg QD x 8 years
Sudafed 60mg Q6 hours PRN sinus drainage
Aleve 1 to 2 tablets QD PRN joint pain
2. Determine appropriateness of home medications:
Hydrochlorothiazide/Triamterene- 25/37.5mg daily for 8 years; not appropriately
controlling his HTN due to his uncontrolled HTN, hyponatremia, hypochloremia,
elevated kidney function, hyperglycemia, and pulmonary edema. Due to the patient’s
electrolyte abnormalities, kidney function and pulmonary edema, he should STOP taking
this medication because those are known possible side effects from the medication.
a) Indications: used to treat hypertension and is not normally the first line of
treatment unless hypokalemia is a known problem from just
hydrochlorothiazide.
b) Interactions: When taking Hydrochlorothiazide/Triamterene, it is important to
avoid taking it in combination with Angiotensin II Receptor Blockers, such as
losartan, because they could increase potassium levels causing hyperkalemia
(Schwinghammer et al., 2021). Taking this medication with Angiotensin-
Converting Enzyme (ACE) Inhibitors, such as Lisinopril, as well as Beta2-
Agonists, such as albuterol, may also cause hyperkalemia (Schwinghammer et
al., 2021). It is also shown that taking an ACE inhibitor with this can also
cause an increased risk for hypotension and risk of nephrotoxicity
(Schwinghammer et al., 2021). Antidiabetic agents, such as metformin, may
have a decreased effectiveness when used with thiazide medications
(Schwinghammer et al., 2021). Using nonsteroidal anti-inflammatory agents
(NSAIDs) such as ibuprofen, can increase the risk of nephrotoxicity, decrease
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CASE STUDY ANALYSIS: HYPERTENSION
the effectiveness of the thiazide medication, and can cause hyperkalemia
(Schwinghammer et al., 2021).
c) Drug Dosing: The dosing for Hydrochlorothiazide/Triamterene ranges
according to patient age, severity of hypertension, and comorbidities.
Normally the dosing is Hydrochlorothiazide 25-50mg with Triamterene 37.5-
75mg, 1 tablet, once per day (Schwinghammer et al., 2021). This dose can be
increased or decreased depending on the results after use.
d) Compliance: Because we are not completely sure about GKC’s compliance
with this medication, we will consider him noncompliant with medication
regimen.
e) Outcomes: Based off of GKC’s blood pressure readings in the office and his
mild hypertensive retinopathy, the Hydrochlorothiazide/Triamterene is not
adequately controlling his hypertension. According to his blood work, GKC is
also having other side effects from the medication, and because of this he
should be taken off of this medication and started on a new medication for his
hypertension.
f) Adverse Effects: Adverse effects of Hydrochlorothiazide/Triamterene include
hyponatremia, hypochloremia, dehydration, hypokalemia, hyperglycemia,
hyperuricemia, and can impact lipids and magnesium levels (Burchum &
Rosenthal, 2019).
Sudafed- 60mg every 6 hours as needed for sinus drainage; Because of the patients
current uncontrolled hypertension, the patient should STOP taking this medication.
a) Indications: used to treat nasal congestion due to cold symptoms or allergies,
used for temporary relief of sinus pressure or congestion.
b) Interactions: When taking Sudafed, it is important to avoid drinking caffeine
or taking any other stimulants due to the increased risk of effectiveness
(Schwinghammer et al., 2021). It is also important to avoid taking any
Monoamine Oxidase inhibitors (MAOIs), such as Fluoxetine, with Sudafed
due to its risk of increased effect which can cause life threatening side effects
(Schwinghammer et al., 2021).
c) Dosing: The dosing for Sudafed varies. Typically, it’s 60mg every 4-6 hours
as needed. If the patient is using sustained release, it is 120mg every 12 hours
as needed, and if it is controlled release, it is 240mg once daily as needed. The
most anyone should have is 240mg in a 24 hour period (Schwinghammer et
al., 2021).
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CASE STUDY ANALYSIS: HYPERTENSION
g) Compliance: Because we are not completely sure about GKC’s compliance
with this medication, we will consider him noncompliant with medication
regimen.
h) Outcomes: Because GKC has uncontrolled hypertension, he should STOP
taking the Sudafed immediately as it can increase blood pressure and also
cause urinary retention and issues with urinating. Because he already has BPH
and suprapubic tenderness with palpation, urinary retention is already possible
(Schwinghammer et al., 2021).
i) Adverse Effects: Adverse effects of Sudafed include rebound congestion,
CNS stimulation, cardiovascular effects such as vasoconstriction, and abuse
due to its addictive qualities (Burchum & Rosenthal, 2019).
Aleve- 1-2 tablets per day as needed for joint pain/discomfort; due to GKC’s risk for
increased hypertension, this is no longer appropriate so he should STOP taking this
medication.
a) Indications: used for mild to moderate pain control and joint inflammation and
discomfort (Schwinghammer et al., 2021).
b) Interactions: When taking Aleve, it is important to avoid taking it with
Angiotensin II Receptor Blockers, such as Losartan, due to its risk of decrease
in renal function as well as causing a decreased therapeutic effect
(Schwinghammer et al., 2021). Taking any ACE inhibitors, such as Lisinopril,
with Aleve can also cause decreased renal function as well as a decrease in
antihypertensive medications also used (Schwinghammer et al., 2021). Using
Aleve with any anticoagulation medications, such as Coumadin, can cause an
increased risk of bleeding (Schwinghammer et al., 2021). Beta-Blockers, such
as metoprolol, can cause a decrease effect of antihypertensive medications
when used with Aleve (Schwinghammer et al., 2021). Loop-Diuretics, such as
Furosemide, when used with Aleve can cause a decrease in diuresis and
increase in nephrotoxicity (Schwinghammer et al., 2021). Salicylates, such as
acetaminophen, can cause an increased risk for bleeding as well
(Schwinghammer et al., 2021). Using Thiazide Diuretics, such as
Hydrochlorothiazide, can increase nephrotoxicity and decrease
antihypertensive medication effects (Schwinghammer et al., 2021). Aleve
should not be taken when drinking alcohol due to its increased risk for GI
bleeding (Burchum & Rosenthal, 2019).
c) Dosing: The dosing for Aleve varies, but there are immediate-release tablets
that are dosed as: 250mg every 6-8 hours as needed for pain, 500mg every 12
hours as needed for pain, and the patient can have up to 1000mg daily
(Schwinghammer et al., 2021). The extended-release tablets are dosed as: 750-
1000mg daily (Schwinghammer et al., 2021).
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CASE STUDY ANALYSIS: HYPERTENSION
d) Compliance: Because we are not completely sure about GKC’s compliance
with this medication, we will consider him noncompliant with medication
regimen.
e) Outcomes: Because of GKC’s uncontrolled hypertension, taking Aleve causes
an increased risk for bleeding, as well as interactions with other medications,
so the patient should STOP taking the medication all together.
f) Adverse Effects: Adverse effects from taking Aleve include constipation,
diarrhea, headache, dizziness, drowsiness, bleeding, and kidney injury
(Burchum & Rosenthal, 2019).
3. Additional Information Needed:
Medication compliance
Frequency of as needed medication (Aleve and Sudafed)
Any history of chest pain or bleeding
Testing such as chest x-ray, ECHO, cardiac stress test, and EKG to determine
extent of heart disease
Urinalysis due to urinary retention, BPH, and suprapubic pain with palpation
PSA level to determine the patients risk of prostate cancer due to his BPH
Bladder scan to see how much urine the patient is retaining as well as a post-void
residual to check for urinary retention
4. Desired Therapeutic Outcome:
a) Short Term Goals:
a. Treat GKC’s uncontrolled hypertension by keeping his blood pressure
<130/80
b. Treat the urinary retention or UTI to improve urinary output and
decrease suprapubic pain
c. Treat the hyperlipidemia by decreasing the amount of salt intake and
improving his lipid panel from his blood work
d. Decrease his overall risk for cardiovascular disease by initiating a
daily aspirin to his medication regimen
e. Low-carb diet/DASH diet
f. Encourage weight loss
g. Increase physical activity by increasing walks to 4 times per week
h. Decrease alcohol intake
i. Keep a daily food and blood pressure log to track progress
j. Ensure patient understands plan and understands to call PCP for any
concerns such as chest pain, shortness of breath, or failure to urinate
k. Schedule follow up in one week to check blood pressure, blood sugar,
and repeat blood work
b) Long Term Goals:
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CASE STUDY ANALYSIS: HYPERTENSION
a. Control hypertension to have a consistent blood pressure of <130/80
b. Prevent UTI’s and retention
c. Decrease his overall risk of kidney infection and injury
d. Control his hyperlipidemia by showing improved lipid panels in his
blood work over time
e. Decrease his HgbA1c level to <7.5%
f. Decrease his overall cardiovascular risk
g. Improve his diet by implementing a low-carb/DASH diet that he is
consistent with
h. Increase his physical activity to 30 minutes per day- walking, biking,
swimming, etc.
D. Plan:
1. Recommendations:
a. Non-Pharmacological Therapy:
i. Maintain blood pressure log for future visits to keep track of BP levels
ii. Maintain a food log to make sure he is complying with dietary plans
iii. Lifestyle Modifications such as weight loss, low carb/DASH diet,
decrease in salt intake, increase physical activity, and decrease alcohol
consumption
iv. Education patient on cardiovascular disease risks and DM Type II
v. Place consults to urology and ophthalmology due to his urinary
retention and hypertensive retinopathy
vi. Repeat all blood work in one month, then 3 months, then as needed
b. Pharmacological Therapy:
GKC has many medical issues, those being his uncontrolled
hypertension, hyperlipidemia, urinary retention, possible DM Type II,
and his risk for cardiovascular disease. Because of all of these issues, a
new medication regimen will be put into place and he will be taken off
of his previous medications.
1) Losartan- Antihypertensive; Angiotensin II Receptor Blocker;
GKC will replace his Hydrochlorothiazide/Triamterene with this. Losartan is
less likely to cause hyperkalemia or have as many side effects as an ACE
inhibitor would, which is why he is not being started on an ACE inhibitor.
Oral Dose: 50mg once per day, based on blood pressure log the dose can be
adjusted as needed; can be adjusted to twice per day with doses ranging from
25-100mg per day with a maximum dose of 100mg per day (Schwinghammer
et al., 2021).
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CASE STUDY ANALYSIS: HYPERTENSION
NEW MEDICATION: Losartan
E or
AE
Parameter Method Goal Alter Tx When/If
E
Lower blood
pressure
Self-monitoring 2x day
and log to report
Monitor with office visits
as well
Blood pressure
to average
<130/80
If blood pressure
is not at goal,
medication can be
titrated during
PCP office visit
AE Hypokalemia
Pt reports heart
palpitations, weakness,
dizziness
Monitoring of lab values
in office visits
To have
normal
potassium
levels between
3.5-5 mg/dL
If pt has low
potassium levels,
additional
medication may
need to be added
or a change in BP
medication
AE Hypoglycemia
Patient self-reports
symptoms
Labs show uncontrolled
HgbA1c
No s/s of
hypoglycemia
and normal
levels on labs
If patient develops
s/s of
hypoglycemia, he
will need to be
seen in office and
have medication
adjustments
AE Hypotension
Patient self-reports with
BP log
Office visit BPs
Patients BP
stays >100
mmHg systolic
but <130
mmHg
If needed
medication can be
titrated by PCP
but if hypotension
persists, stop
taking medication
and call PCP
AE Cough Patient reports coughing
As long as
cough does not
interfere with
activities of
daily living
If cough becomes
too much, call
PCP and do not
take next dose of
medication
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CASE STUDY ANALYSIS: HYPERTENSION
2) Aspirin- Nonopioid analgesic; NSAID; salicylate; antiplatelet agent
GKC will be started on a daily aspirin 81mg because of his cardiovascular
disease risk factors. Due to his hypertension, hyperlipidemia, alcohol intake,
and lack of exercise, that greatly increases his risk for heart attack or stroke,
so by beginning a daily antiplatelet agent that reduces his risk significantly.
Oral Dose: Average dose is 81mg daily in the morning. The tablets can be
chewable or EC (enteric coded) (Schwinghammer et al., 2021).
NEW MEDICATION: Aspirin
E or
AE
Parameter Method Goal Alter Tx When/If
E
Decreased
Cardiovascular Risk
Self-monitoring
Adhering to medications
Lab Results at PCP apts.
No
cardiovascular
events
including heart
attack or stroke
If patient begins to
have
cardiovascular
events/symptoms,
call PCP for
further treatment
AE
Hyperkalemia,
Hypernatremia
Self-monitoring with
symptom reporting
Lab values at PCP office
Normal
potassium and
sodium levels
from lab work
If lab values are
still abnormal,
stop taking the
medication and
reevaluate
medication
regimen
AE
Decreased Kidney
Function/Kidney
injury
Self-monitoring urine
output
Labs show decreased
BUN and Creatinine
Normal kidney
function/lab
values of BUN
and Creatinine
If lab values are
elevated, stop
taking the
medication and
have PCP change
medication
AE Hemorrhage
Self-reports bleeding
Lab values and hemocult
No bleeding
and normal lab
values
If there is
bleeding, call PCP
and do not take
the next dose
AE Hepatotoxicity
Lab values show
increased ALT and AST
Lab values
show normal
liver function
If lab values show
increased liver
function, PCP will
tell him to stop
taking medication
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CASE STUDY ANALYSIS: HYPERTENSION
3) Atorvastatin- Antilipidemic agent
GKC will be started on atorvastatin due to his lipid panel results. Lipids are a
cause of cardiovascular disease and stroke and having high levels of LDL and low
levels of HDL means he is high risk for clots due to plaque buildup in his arteries
(Burchum & Rosenthal, 2019).
Oral Dose: For moderate cardiovascular risk, the dose starts at 10-20mg tablet
once a day. For high cardiovascular risk, the dose ranges between 40-80mg tablet
per day (Schwinghammer et al., 2021).
NEW MEDICATION: Atorvastatin
E or
AE
Parameter Method Goal Alter Tx When/If
E Decreased
Hyperlipidemia
Lab values show decrease
in LDL and increase in
HDL levels
Have a normal
lipid panel
from blood
work
If lipid panels are
abnormal, PCP
will titrate dose as
needed
AE Hemorrhagic stroke
Patient self-reports stroke
like symptoms- weakness,
slurred speech, paralysis
of one side of body
To have no
stroke like
symptoms or
bleeding
If pt has any s/s of
stroke or bleeding,
call 911 and be
evaluated at
hospital
AE Diarrhea Patient self-reports
No diarrhea
reported from
patient
If patient develops
diarrhea, do not
take next dose and
call PCP
AE Nausea Patient self-reports
stomach issues
No GI upset
that interferes
with activities
of daily living
If patient has
stomach issues, do
not take next dose
and call PCP
AE Arthralgia Patient self-reports joint
pain
To have no
joint pain
If pain increases
or persists, tell
PCP and do not
take next dose
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CASE STUDY ANALYSIS: HYPERTENSION
4) Metformin- oral anti-hyperglycemic
GKC’s lab values are showing he is now a DM Type II due to his HgbA1c being
8.5% and fasting glucose of 181 mg/dL. These levels indicate he is now within
diabetic range and will need medication to treat his blood glucose level because
this creates an increased risk of cardiovascular disease.
Oral Dose: starting dose is 500mg daily with supper at night and if tolerated or
not enough, can be increased to 500mg twice daily with breakfast and supper,
with a maximum dose of 2250mg daily (Schwinghammer et al., 2021).
NEW MEDICATION: Metformin
E or
AE
Parameter Method Goal Alter Tx When/If
E Lower BG level
Self-monitoring 2x day
and log to report
Laboratory Results of
HgbA1c Q 3 months
Short term
HgbA1c of
<7.5%
BG between
80-130 mg/dL
Long term
HgbA1c of
7.0%
If HgbA1c is not
improved at 3
month check,
increase dose of
metformin and
monitor BG levels
AE Hypoglycemic
Reactions
Patient self-reports
Patient monitors BG
levels at home
To have no
hypoglycemic
events
If pt continues to
have
hypoglycemic
episodes, instruct
to take with meals
to counteract
AE Lactic Acidosis
Patient self-reports
symptoms
Labs- increased Lactic
level
No symptoms
of lactic
acidosis and
normal lab
values for
lactic level
If patient develops
s/s of lactic
acidosis, send to
ER for evaluation
AE Gastrointestinal
Upset
Patient self-reports
stomach issues
No GI upset
such as nausea,
vomiting,
diarrhea,
constipation,
or abdominal
If patient has
these symptoms,
check BG levels
and make apt to
be seen in office
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CASE STUDY ANALYSIS: HYPERTENSION
pain
5) Tamsulosin- Adrenergic Antagonist, used to treat BPH
GKC will be started due to his urinary retention and BPH which will be diagnosed
with a post void residual and bladder scan pre and post void.
Oral Dose: dose starts at 0.4mg once daily 30 minutes after a meal, preferably the
same meal each day. The dose may be increased 3-4 weeks post initiation to
0.8mg once daily in patients who fail to respond to the initial therapy
(Schwinghammer et al., 2021).
NEW MEDICATION: Tamsulosin
14
E or AE Parameter Method Goal Alter Tx
When/If
E
Relaxation of
the bladder and
prostate
Pt reports ease of urinating
Improvement of
urine flow and
ease of urinating
If pt unable to
void, do not take
next dose seek
emergency
medical care
AE Chest pain Pt self-reports this
No chest pain
reported
If pt has chest
pain, do not take
next dose and
seek emergency
care
AE Priapism Pt self-reports this
No erection
lasting longer
than normal for
the pt
If pt does have
issues, do not
take next dose
and seek
emergency care
AE
Orthostatic
Hypotension
Pt self-reports this in BP log
and from monitoring in PCP
office
Pt has no
hypotension
If pt has low BP,
do not take next
dose and call
PCP
AE Headache Pt self-reports headaches
Pt has no
headaches that
interfere with
activities of daily
living
If pt has
headaches, do not
take next dose
and call PCP
CASE STUDY ANALYSIS: HYPERTENSION
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Hua, D., Xu, Y., Zhang, X., He, T., Chen, C., & Chen, Z. (2021). Retinal Microvascular Changes
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