Station 42
Andrew Coleman
Age: 50 years old male
Examiner
Marking Scheme
Data Gathering and Diagnosis
- Ask about symptoms of possible end organ damage such as headache, blurry vision (hypertensive retinopathy), chest pain (acute coronary syndrome/hypertensive heart disease), SOB (Heart failure), palpitations (acute coronary syndrome/hypertensive heart disease), ankle oedema (Heart failure), blood in urine (Hypertensive nephropathy), stroke symptoms—weakness in one sided body, slurred speech.
- Explore lifestyle factors including diet, physical activity, smoking, alcohol, and recreational drug use
- Ask about any family history of hypertension or cardiovascular disease
- Ask about the wrist injury—whether there is ongoing pain, swelling, signs of infection, or further follow-up planned
- Make a working diagnosis of probable essential hypertension, explaining that a confirmed diagnosis cannot be made based on single elevated readings
Example of explanation to patient
Andrew, thank you for sharing your concerns, it’s completely understandable to feel worried after hearing your blood pressure was high. When you’re in pain or feeling stressed, like during your visit to A&E, your blood pressure can temporarily rise. That might explain the readings they found at the time.
That said, it’s also possible that your blood pressure is genuinely elevated, and this can develop gradually over time without causing any obvious symptoms. That’s why we take it seriously, even if you feel completely well.
The most important next step is to confirm whether your blood pressure is consistently high, a condition we call hypertension. There are two ways we can do this.
One option is to use a 24-hour blood pressure monitor. This is a device that stays attached to your upper arm and is connected by a tube to a small monitor, which you wear on your waist or carry in a pouch. It takes readings automatically throughout the day and night while you go about your usual activities, and you wear it continuously for 24 hours.
The second option is for you to use a home blood pressure machine to check your blood pressure twice a day, morning and evening, for at least 4 days, ideally 7. We’ll give you a recording sheet to write down your readings.
While we’re organising this, I’d also like to arrange some routine tests. These include blood tests to check your blood sugar, cholesterol, and kidney function, as well as a urine test to look for any signs of kidney involvement. I’d also like to do an ECG — a heart tracing — and examine the back of your eyes for any blood pressure-related changes.
Would you be happy to come in today so we can get started with this?
Management
- Offer ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) to confirm diagnosis
- Offer face-to-face appointment to repeat blood pressure, perform cardiovascular examination, fundoscopy and arrange further investigations including HbA1c, cholesterol, U&Es, urine ACR, and ECG
- If fundoscopy cannot be performed in the clinic, advise the patient to book an appointment with a high street optician for a comprehensive eye examination
- Offer to calculate QRISK score to assess cardiovascular risk
- Give lifestyle advice: increase physical activity, reduce salt and caffeine intake, and follow a healthy diet
- Explain that if hypertension is confirmed, treatment will be started with Ramipril 1.25–2.5 mg; and you can mention possible side effects like cough
- Informs patient of blood pressure targets: clinic BP <140/90 mmHg, or home BP <135/85 mmHg
- Arrange follow-up in 24hrs (ABPM) or 4-7days (HBPM) toreview blood results and discuss ABPM or HBPM findings
- Safety net by advising the patient to seek urgent medical attention if they develop any concerning symptoms such as sudden weakness (which may suggest a stroke), blurred vision, chest pain, or shortness of breath.
Learning point from this station:
Elevated blood pressure readings in acute settings like A&E require confirmation before diagnosing hypertension. Blood pressure can be transiently raised due to pain, stress, or physical activity, and may not reflect true hypertension.
According to NICE, if a person has a clinic blood pressure between 140/90 mmHg and 180/120 mmHg, diagnosis should be confirmed using ambulatory blood pressure monitoring (ABPM), or home monitoring (HBPM) if ABPM is unsuitable.
If blood pressure is ≥180/120 mmHg, same-day referral is needed if there are signs of retinal haemorrhage, papilloedema, or life-threatening symptoms such as confusion, chest pain, signs of heart failure or acute kidney injury (blood or protein in urine on dip stick testing or blood test confirming AKI if available)
If no red flag symptoms or signs are present, investigations for target organ damage should be arranged promptly. If organ damage is identified, antihypertensive treatment should be initiated immediately without waiting for ABPM or HBPM results. If no target organ damage is found, repeat blood pressure measurement within 7 days.
https://cks.nice.org.uk/topics/hypertension/