Hypertension is a common patient presentation. Patients may not state hypertension as their chief complaint but elevated blood pressure is often identified during a clinical encounter. Hypertension is a common medical condition with over 30% adults in the US. Most causes of hypertension are essential. Secondary causes are listed on this clinical mind map and must be investigated if suspected based upon certain clinical features. Generally speaking, onset of hypertension at a young age (less than 35 years old) or an old age (greater than 55 years old), resistant hypertension, and hypertension with rapid end organ failure are indications for a work up for secondary hypertension.
Using the Epi-logical approach, essential hypertension must be considered when evaluating 35 to 55 year-old patients in the absence of clinical features consistent with secondary causes of hypertension. In addition, obstructive sleep apnea, medications, and drug and alcohol use should be considered as exacerbating factors. All causes of secondary hypertension must be strongly considered in patients less than 35 years old and over 55 years old with the onset of hypertension and in patients with features consistent with secondary causes.
Urgent/emergent situations include hypertensive urgency (blood pressure greater than 180/120) or emergency (end organ failure). In such cases, patient presentation may include altered mental status sue to hypertensive encephalopathy, shortness of breath due to hypertensive pulmonary edema, visual disturbances due to hypertensive retinopathy, and decreased or abnormal urine output due to hypertensive nephropathy. If any of these situations exist, steps must be taken to manage the situation appropriately.
Next, weighing and removing anchor bias involves a clinician asking questions and doing a physical exam to look for 1) features consistent with secondary hypertension, which are listed in this clinical mind map in front of the individual diagnoses and 2) features suggestive of complications of hypertension, which include symptoms and signs of heart failure and chronic kidney disease, etc.
Labs and tests must be ordered to look for secondary causes as well as end organ complications.
A helpful mnemonic to remember etiologic categories of hypertension is RESPEWD