Non-controlled Hypertension (HT) 54 female patient.
High blood pressure is associated with many health conditions like cardiovascular disease, stroke, kidney disease, and premature death. Treatment of Hypertension is multimodal which involves patient’s medication, lifestyle change, patient education and blood pressure monitoring (Elmakki, 2024). In this case study, treatment of a 54-year-old woman with uncontrolled hypertension, hyperlipidemia and type 2 diabetes mellitus (T2DM) will be discussed. Patient-specific treatment plan developed based on evidence-based guidelines to reduce patient’s risk for cardiovascular disease from the treatment of Hypertension, hyperlipidemia and T2DM.
Patient Overview
Mrs. Helen Hurst is 54 years old woman presenting with Hypertension (not controlled in her current antihypertensive treatment with Lisinopril 20mg once daily). At this visit, her blood pressure reading was 160/100, which is a stage 2 hypertension reading. Other cardiovascular disease risk factors for Mrs. Hurst are type 2 diabetes mellitus, hyperlipidemia, overweight (BMI 28 kg/m2), not exercising, unhealthy lifestyle and family history of cardiovascular disease. May be at risk of developing future cardiac related symptoms. She does not have any symptoms relating to her Hypertension (e.g., chest pain, headache, dizziness).
First-Line Pharmacological Treatment
The first line treatment for Mrs. Hurst’s uncontrolled Hypertension would be to add a thiazide diuretic and/or a calcium channel blocker to an ACE. For people who have stage 2 Hypertension, two or more drugs used to treat high blood pressure should be used. ACE inhibitors are recommended to be continued for those with Hypertension and diabetes for Cardiovascular protection, and to protect the kidneys. An extra antihypertensive drug should be used due to uncontrolled Hypertension and one drug. Kayes et al. (2024) suggest that a thiazide diuretic (hydrochlorothiazide or chlorthalidone) should be used. The drugs act by decreasing the sodium and water in the body, which play a role in regulating blood pressure. The drug of choice is chlorthalidone due to its longer duration of action. Another class of drugs that could be used in treating this patient is a calcium channel blocker. Amlodipine is a type of these medicines. These drugs are indicated in the treatment of Hypertension because they act differently to the ACE inhibitors. So these drugs can be prescribed for Mrs. Hurst.
Alternative Medications
Options are available other than the drugs that are the first line treatment for Hypertension. If the patient does develop a cough or angioedema while taking an ACE, they can try another medication that belongs to a group different from ACE inhibitors called an angiotensin II receptor blocker (ARB), such as Losartan. ARBs provide the same benefits to the kidney and heart as ACE inhibitors but have fewer negative effects on the respiratory system. Patients with coronary artery disease, arrhythmia and heart failure may take beta blockers like Metoprolol. These are not the drugs of first choice, however, for patients with Hypertension only. In cases where other drugs are not effective in hypertension, then spironolactone can be used as an alternative drug. Besides its sodium excretory properties, spironolactone has been shown to be an effective antihypertensive drug in resistant Hypertension. Thus, these drugs can be used as an alternative to the first line drugs for the treatment of Hypertension.
Discuss the rationale for the choice of the drug. Explain why to choose the drug.
This is because people who have diabetes and Hypertension are highly recommended to use an ACE inhibitor, because of the advantages it offers. Since patient Hurst is at risk of developing kidney disease (diabetic nephropathy) due to her diabetes, the ACE therapy will help. A thiazide diuretic may also help to keep her blood pressure low; her blood pressure is still elevated when she takes her blood pressure medicine. It is preferable to take two drugs for the treatment of blood pressure than a single one. In addition, Amlodipine is a possibility, because calcium channel blockers have been proven to treat Hypertension in adults with stage 2 hypertension. In general, these are the drugs recommended for a patient with Hypertension (Hurst’s).
Nonpharmacological Interventions
There are several different nonpharmacological interventions that can be recommended to Mrs. Hurst. The first measure that can be taken is the suggestion of the DASH Diet (Dietary Approaches to Stop Hypertension). DASH is a diet that emphasizes fruits and vegetables, whole grains, lean protein and low-fat dairy products and reduces the amount of sodium in the diet. Another intervention that could be used for Mrs. Hurst is a recommendation for physical activity. The suggestion is to have aerobic exercise for 150 minutes a week. Also, weight loss may be encouraged for Mrs. Hurst. Since Mrs. Hurst is overweight, losing weight will be a huge help in helping control her blood pressure. Moreover, people who enjoy activities that are relaxing like yoga and meditation can get their blood pressure reduced considerably via this. Last but not least, reducing Mrs. Hurst’s sodium intake to less than 2.3 grams a day will also help her manage her blood pressure.
As per Evidence Based Guidelines
All these nonpharmacological interventions for Hypertension are consistent with recommendations from the International Society of Hypertension and JNC8 recommendations as well as the American Heart Association. All of these professional organizations recommend that patients with HTN try to control their condition with diet, exercise, weight loss, reduction in sodium intake and cessation of smoking. In addition, these recommendations have all been shown to have a positive effect on patients with HTN in clinical trials when combined with pharmacologic therapy to treat HTN.
Lifestyle Modifications
There are a number of things that could be done in the lifestyle of Mrs. Hurst. A few adjustments that might be helpful are to cut down on eating processed foods. A lot of common grocery foods contain lots of sodium and bad fat. Increasing her consumption of fruits and vegetables will increase her potassium intake, which will help to lower her blood pressure. Another would be to start a routine to exercise her cardiovascular system regularly to enhance it. Furthermore, Mrs. Hurst will gain a lower weight if she manages to lose weight which will also bring her diabetes and Hypertension under control. Last but not least, decreasing her drinking will also help lower her blood pressure. Each of these changes will help decrease her Blood pressure and her risk of complications from her Hypertension, diabetes and Cardiovascular system.
Monitoring and Follow-Up
It will be important to monitor Mrs. Hurst’s blood pressure at home and in the clinic to determine the effectiveness of the treatments she receives. It will be important for Mrs. Hurst to have a record of her blood pressure readings to present to her doctors at follow-up appointments, to give them a general idea of her blood pressure. Routine blood tests will also be necessary in Mrs. Hurst to check kidney function, glucose and electrolyte levels. These tests are essential to make sure that the medicine given to Mrs. Hurst is not adversely affecting how her kidneys are working and her potassium levels. Finally, as Mrs. Hurst’s blood pressure medicine may have side effects, it will be crucial to monitor her for any side effects from this medicine.
Follow-Up Appointments & Tests
Mrs. Hurst will need to have her blood pressure rechecked by her doctor in 2-4 weeks and be making sure that she is tolerating the medication.
Repeat the following blood tests:
- Serum creatinine
- Potassium levels
- HbA1c
- Lipid profile
In addition, it is important to conduct an annual cardiovascular risk assessment, and a diabetic screening, to monitor the disease and the prevention of disease.
Offer patient/family education.
The patient should be aware of the importance of taking the medications, even if not feeling any symptoms. If Mrs. Hurst does not control her Hypertension the risk to her body is increased. In addition, it is crucial to educate the patient and her family about the signs of a hypertensive emergency, which would be treated urgently. Finally, remind people at each office visit of lifestyle and dietary changes.
Pharmacodynamics
Lisinopril is a type of drug called an ACE inhibitor. It is an inhibitor of the enzyme which converts angiotensin I to angiotensin II and is used to reduce blood pressure. This angiotensin II compound produces the normal constriction of blood vessels and secretion of aldosterone by the adrenal glands. Antagonizes the effects of angiotensin II, which lowers blood pressure. CO is directly proportional to BP, SVR. Chlorthalidone is a potassium-sparing diuretic that works in the kidney at the distal convoluted tubule to increase the amount of chloride and sodium ions excreted by the kidney as well as the amount of water excreted from the body (Herman et al., 2023). Amlodipine belongs to a group of medications known as calcium channel blockers which relax the blood vessels in the body.
Pharmacokinetics
After being taken by mouth, the body absorbs lisinopril, which is excreted in its original (unchanged) form in the urine. Treatment with this drug should be monitored for the patient’s renal function. Chlorthalidone is extensively metabolized and has a long half-life. Amlodipine is extensively metabolized by liver. Hence, before prescribing this to patients, the liver function should be considered. Pharmacokinetics of the medications is significant and any patient with diabetes is at risk for renal impairment, like Mrs. Hurst.
Drug Classification
- Lisinopril: ACE inhibitor
- Chlorthalidone: Thiazide-like diuretic
- Amlodipine belongs to the group of drugs known as calcium channel blockers.
They are classified so because they are used as the first line treatment for Hypertension and diabetes.
Adverse effects and safety,
Some of the side effects of lisinopril are angioedema, renal impairment, hyperkalemia, cough, and hypotension. However, the patients’ renal functions and potassium levels can be monitored to mitigate the adverse effects that these can have on the patients. Side effects that may be caused by chlorthalidone include hypokalemia (low potassium), dehydration, hyperglycemia (high blood sugar), and dizziness. A way to assess the electrolyte status of the patient is to monitor the electrolyte levels in the patient while maximizing the therapeutic benefits of chlorthalidone and minimizing any potentially adverse effects caused by chlorthalidone. Amlodipine’s side effects include peripheral edema, dizziness, headache and flushing. An important part of caring for the patient is monitoring for signs of swelling and hypotension, to ensure that the beneficial effects of the drug therapy are being achieved while reducing the negative effects of therapy. Lastly, educating the patients about the adverse effects of these medications will ensure that patients will be more likely to take their medications as prescribed, thereby enhancing the safety of the patients as well as the effectiveness of these medications (Lopez et al., 2024).
Conclusion
Mrs. Helen Hurst has uncontrolled Hypertension (Stage 2), which is complicated by a number of other risk factors. Treatment will have to be multimodal in order to improve her hypertension and risk factors. Two choices for her to consider are continuing her ACE inhibitor and adding a calcium channel blocker or thiazide. After these treatments have been implemented, Mrs. Hurst’s blood pressure should be lowered, and she will no longer be at risk for long-term damages to her blood pressure.
References
Elmakki, E. (2024). The Role of Lifestyle Modifications in Preventing and Managing Systemic Hypertension: Current Guidelines and Future Directions. Annals of African Medicine, 24(1), 1–8. https://doi.org/10.4103/aam.aam_90_24
Herman, L. L., Padala, S. A., Ahmed, I., & Bashir, K. (2023, July 31). Angiotensin-Converting Enzyme Inhibitors (ACEI). Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK431051/
Kaye, A. D, Corley, S. C., Ingram, E., Issa, P. P., Roberts, L. T., Neuchat, E. E., Sharpe, M. J., Doan, N., Willett, O., Kaye, A. M., Shekoohi, S., & Varrassi, G. (2024). The Evolving Role of Chlorthalidone and Hydrochlorothiazide as First-Line Treatments for Hypertensive Patients. Cureus. https://doi.org/10.7759/cureus.63841
Lopez, E. O., Parmar, M., Satish Pendela, V., & Terrell, J. M. (2024, October 5). Lisinopril. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482230/
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Case Study Questions
What are the first-line pharmacological treatment options for this case? Provide a detailed explanation of why each medication is appropriate.
What alternative medications could be considered if the first-line treatments are not effective or suitable? Justify your rationale for each alternative.
Why did you choose the specific drug(s) for this patient? Explain how they align with the patient’s clinical presentation.
What nonpharmacological strategies would you recommend for this patient? Be specific in your suggestions.
How do these non-pharmacological strategies align with current evidence-based guidelines?
What lifestyle changes should the patient implement, and how will each modification contribute to their treatment?
What monitoring strategies will you recommend for this patient, and why are they important?
What specific follow-up appointments or tests should the patient have to ensure effective monitoring of their condition?
What will you explain to the patient and their family about the importance of medication adherence?
How will you educate them about necessary lifestyle changes and the need for consistent monitoring and follow-up?
How do the chosen drugs work at a pharmacodynamic level?
How are the chosen drugs metabolized, and why is this important in this specific case?
What class does the chosen drug(s) belong to, and why is it appropriate for this patient?
What are the potential adverse effects of these medications, and how will you monitor or mitigate these effects?
Week 2: Learning Materials
• Rosenthal, L. D., & Burchum, J. (2025). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (3rd ed.). Elsevier.
o Drugs That Affect the Heart, Blood Vessels, Blood, and Blood Volume
Chapter 36: Review of Hemodynamics (WO 1, 3, 4)
Chapter 37: Diuretics (WO 1, 3, 4)
Chapter 38: Drugs Acting on the Renin-Angiotensin-Aldosterone System (WO 1, 3, 4)
Chapter 39: Calcium Channel Blockers (WO 1, 3, 4)
Chapter 40: Vasodilators (WO 1, 3, 4)
Chapter 41: Drugs for Hypertension (WO 1, 3, 4)
Chapter 44: Prophylaxis of Atherosclerotic Cardiovascular Disease Drugs That Help Normalize Cholesterol and Triglyceride Levels (WO 2, 3, 4)
Recommended Resources
• 2018 AHA/ACC Multisociety Guideline on the Management of Blood Cholesterol (WO 1, 2, 3, 4)
• JNC8 (WO 1, 2, 3, 4)
• 2020 International Society of Hypertension Global Hypertension Practice Guidelines (WO 1, 2, 3, 4)
• Links to Important Calculators to Guide Prescribing (Word) (WO 1, 2, 3, 4)
• Medscape by WedMD LLC. Drug Interaction Checker (WO 1, 2, 3, 4)
• Medscape by WebMD LLC. Cardiovascular (Create a free account to obtain information) (WO 1, 2, 3, 4)
Primary Care (Women, Family, Adult) SOAP Note Case Study
Patient: Mrs. Helen Hurst
Age: 54 years old
Visit Type: Primary Care
Chief Complaint: “I know my blood pressure is high.”
Subjective
HPI
Mrs. Helen Hurst is a 54-year-old woman presenting to the primary care office for evaluation and management of her uncontrolled hypertension. She has a history of elevated blood pressure readings at home over the past 6 months. She denies any associated symptoms such as headaches, dizziness, chest pain, shortness of breath, or palpitations. She adheres to her current medication regimen but has not seen any significant improvement in her blood pressure readings. Mrs. Hurst is seeking advice on how to better control her hypertension.
ROS
• General: Denies fever, fatigue, weight loss, or weight gain.
• Cardiovascular: Denies chest pain, palpitations, or edema.
• Respiratory: Denies shortness of breath, cough, or wheezing.
• Gastrointestinal: Denies nausea, vomiting, diarrhea, or constipation.
• Genitourinary: Denies dysuria, hematuria, or frequency.
• Neurological: Denies headaches, dizziness, or syncope.
• Musculoskeletal: Denies joint pain or muscle weakness.
• Endocrine: Denies polyuria, polydipsia, or heat/cold intolerance.
• Psychiatric: Denies anxiety or depression.
Past Medical History
• Hypertension (diagnosed 5 years ago)
• Hyperlipidemia
• Type 2 diabetes mellitus
Surgical History
• Appendectomy (age 30)
• Cholecystectomy (age 45)
Family History
• Father: Deceased at age 70, history of hypertension and myocardial infarction
• Mother: Alive, age 78, history of hypertension and stroke
• Siblings: Two brothers, both with hypertension
Social History
• Occupation: Accountant
• Marital Status: Married
• Tobacco Use: None
• Alcohol Use: Occasional wine (1-2 glasses/week)
• Illicit Drug Use: Denies
• Diet: Reports a diet high in processed foods and low in fruits and vegetables
• Exercise: Sedentary lifestyle, minimal physical activity
Sexual History
• Monogamous relationship with husband
• Denies any history of sexually transmitted infections (STIs)
Medications
• Lisinopril 20 mg daily
• Metformin 1000 mg twice daily
• Atorvastatin 40 mg daily
Allergies
• Penicillin (rash)
Objective
Vital Signs
• Blood Pressure: 160/100 mmHg (right arm, seated)
• Heart Rate: 78 bpm
• Respiratory Rate: 16 breaths/min
• Temperature: 98.6°F
• BMI: 28 kg/m²
Physical Exam
• General: Well-nourished, well-appearing woman in no acute distress.
• Cardiovascular: S1 and S2 normal. No murmurs, rubs, or gallops. No peripheral edema.
• Respiratory: Lungs clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
• Gastrointestinal: Abdomen soft, non-tender, no hepatosplenomegaly.
• Neurological: Alert and oriented x3. Cranial nerves II-XII intact. No focal deficits.
• Musculoskeletal: Full range of motion in all extremities. No joint swelling or tenderness.
• Skin: No rashes or lesions.
Assessment
1. Uncontrolled Hypertension