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Hypertension-Clinical evaluation of hypertensive patients, Anamnesis, Procedures
Clinical evaluation of hypertensive patients
The history of the hypertensive patient should be collected to detail and enriched by information provided by close relatives or other medical or paramedical personnel who have served in the past, if applicable. Hypertension is an asymptomatic disease par excellence, so much so that it has been called "the silent murderer," and therefore would not be surprising that many symptoms are not harvested in history, or that these symptoms are nonspecific (headache, dizziness and visual disturbances, for example). Once clearly defined the reason for visit and having the relevant data documented in this disease must be emphasized from the first consultation on the following:
• Cardiovascular risk factors, traditional and nontraditional;
• Family history of disease, particularly if there has been cardiac deaths in children under 50 years consanguineous (first degree: parents, siblings, children);
• Socio-economic status, cultural and professional, familial status, access to systems of health, education, environmental factors and / or situational causes of stress;
• Exhaustive list of comorbidities (usually history by interrogating systems);
• Dietary and hygiene habits: coffee, tea, carbonated drinks, alcohol, snuff, sodium, diet, physical activity;
• High glucose level and high consumption of glucose (If you have Diabetes)
• Exposure to drugs that can cause hypertension (ephedrine, methylphenidate, ergotamine, etc.);
• Allergies and intolerances;
• Symptoms, cardiovascular (dyspnea, orthopnea, paroxysmal nocturnal dyspnea, precordialgia, palpitations, syncope, edema, intermittent claudication) or nonspecific (headache, dizziness, tinnitus, visual disturbances, cognitive impairment, fatigue, mood changes, erectile dysfunction, by example);
• Prior cardiovascular events: transient cerebral ischemia, stroke, angina pectoris, myocardial infarction, congestive heart failure, chronic renal failure among others;
• Previous or planned surgical procedures.
• This information is vital to the overall assessment of cardiovascular risk in every hypertensive patient. Every element of risk or clinical diagnosis, resolved or not (treated or untreated), every symptom, every history should be included in a list of problems. This will help the overall treatment plan without forgetting important points.
Procedures for accurate measurement of blood pressure
The taking of blood pressure in patients at high risk should be properly in order to avoid false negatives and false positives even.
• The individual should preferably be seated with his back against the seat back and upper limbs should rest on the desk surface, the forearm in pronation, the height of the heart, the soles of the feet should be flat on the floor legs uncrossed.
• After a few minutes rest (preferably 5 minutes, perhaps during or after interrogation) is placed a cuff of appropriate size (to cover 2 / 3 of the arm's length) and in good condition in the upper arm of patient must not have clothing between skin and the cuff, which should be snug but not so as to prevent the introduction of the little finger between it and the skin. If the roll up the shirt or blouse fabric compresses the member must withdraw best clothes and ask the patient to not wear a gown to physical examination. Caution: in some patients can not use one arm for blood pressure measurement: amputation, history of radical surgery in armpit, or the presence of an arteriovenous fistula, for example).
• Preferably use a mercury column sphygmomanometer, which will be reviewed and adjusted periodically. The base of the tensiometer and the center of the cuff should be at the patient's heart level to avoid errors of measurement. If you have only sphygmomanometer must be verified to be well calibrated. Should be available in at least three sizes of sleeves, including one for obesity and other pediatric patients, which could be useful in very old people with great muscular atrophy and / or low adiposity.
• The procedure of taking blood pressure control should not be uncomfortable or painful. The cuff is inflated at least 20-30 mmHg above the pressure needed to clear the pulse of the wrist or elbow, or until it has passed a pressure of 220 mm Hg. Then, applying the stethoscope over the brachial artery, deflated slowly until they are audible for the first time the Korotkoff sounds (systolic pressure). The early disappearance of the noise and subsequent reappearance, called auscultatory gap or gaps (a) is common in older people, so it should be followed slowly deflate the cuff until no doubt of the termination of the noise (Korotkoff phase V, diastolic pressure). In some patients sounds never go away, so diastolic pressure is measured when the intensity change (Phase IV). At all times the observer must be at the level of the mercury column, to avoid misjudgements.
• By deflating the cuff is critical that the patient's limb is still.
• In the first consultation would be ideal to take the pressure in both arms and let them set on what is highest, to be removed from the file, then the measurements should be continued in the same arm. The measurements of BP with the patient standing is highly desirable in the elderly, the patient should be left standing for at least 1 minute before taking the measurement.
• If you make successive shots, as is advisable (you can even make a final measurement before the patient leaves the office), it shall be an interval of at least one minute between each measurement.
• No pressure numbers should be rounded. With good technique you can sign up the pressure with a level of accuracy of 2 mm Hg.
• All the concepts explained above also apply to electronic blood pressure monitors available in the market. It will look brand certified by the Food and Drug Administration (FDA) of USA, or other national institutions, preferably with a brachial cuff. The physician must personally teach their patients the use of these devices and the correct sequence of procedures for home measurements are reliable. An estimated pressure numbers at home are on average 5 mm Hg lower than in the office, both for the systolic and diastolic.
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