Betty is a 45 year old woman with normally well treated hypertension on Perindopril 5mg daily who was noted to have BPs of 165/98 and 158/75 at the last two consults.  She has been putting on weight recently, not sleeping well and hence a bit more tired than usual.  She has put this down to being really busy with work and family.

What are the differentials for this raised Blood Pressure? List 6

1. Essential hypertension
2. Aldosteronism
3. Obstructive Sleep Apnoea
4. Non-compliance
5. Cushing disease
6. Thyroid disease

Note:

“In middle-aged adults, aldosteronism is the most common secondary cause of hypertension, ” https://www.aafp.org/afp/2010/1215/p1471.html

Thyroid disease- hypo or hyper – https://www.medscape.com/viewarticle/733788

How would you confirm whether this was an isolated reading or whether there were systemic issues?

1. 24 hour ambulatory blood pressure measurement

Additional testing as described above is performed and confirms consistent elevation at 168/100.

What pharmacological strategies could be implemented to control the Blood Pressure? (List 5) (List doses etc)

1. Increase Perindopril Arginine to 10mg daily
2. Add Amlodipine 5mg daily
3. Add hydrochlorothiazide 12.5 mg orally, daily
4. Add atenolol 25mg orally, daily
5. Change to hydralazine 12.5 mg orally, twice daily, up to 200 mg daily in divided doses

Other acceptable options

moxonidine (physiotens), prazosin, methyldopa, clonidine, amiloride, spironolactone – https://www.heartfoundation.org.au/images/uploads/publications/PRO-167_Hypertension-guideline-2016_WEB.pd

What lifestyle choices contribute to raised Blood Pressure? (List 8)

1. Limited physical activity
2. Obesity
3. Smoking
4. Alcohol
5. Recreational drugs
6. Diet
7. Stress
8. Disruption of circadian rhythms

 

References:

https://patient.info/doctor/hypertension

https://www.aafp.org/afp/2010/1215/p1471.html

https://www.racgp.org.au/afp/2013/june/hypertension/

https://www.heartfoundation.org.au/images/uploads/publications/PRO-167_Hypertension-guideline-2016_WEB.pdf

https://www.aafp.org/afp/2017/1001/p453.html

 

RACGP Feedback – Case 14

This case focused on a female patient with previously well-treated hypertension who is noted to have raised systolic and diastolic blood pressure during a consultation for repeat prescriptions. Candidates were required to provide possible causes for this raised systolic and diastolic blood pressure given the patient’s history, as well as ways to confirm whether this is an isolated reading or there are issues with blood-pressure control.

The case continues and confirms that the patient’s blood pressure is not fully controlled and candidates were required to provide pharmacological strategies to address this situation. When a question asks for lifestyle factors contributing to uncontrolled hypertension, providing pharmacological causes will not score. It is important to read the question and provide answers that address the question, as well as ensuring answers are not grouped.

Writing ‘smoking’ and ‘alcohol’, or ‘high-fat diet’ and ‘high-salt diet’ on one line is providing more than one answer and will thus lead to over-coding penalties. When responding to a question that asks for specific pharmacological management, simply listing medications or providing non-specific answers such as ‘titrate medication’, ‘maximise dose’ or ‘add diuretic’ will not gain marks. This was the most common error in this question and the primary reason candidates did not score well.

RACGP Conclusion on Technique

As outlined above, there are some common themes and key issues to consider when approaching the KFP exam:

• The KFP exam is not a simple short-answer paper. You must answer the question in the context of the clinical scenario provided, utilising all of the information provided. Read the scenario at least twice.
• Keep your answers succinct.
• Only provide the number of answers requested. Review your answer – have you created a list rather than one answer per line? If so, you will be penalised for extra answers.
• Always read the question at least twice and, after you answer, check that you have answered the actual question asked.
• Be specific in your answers, whether in the investigations being ordered or the treatment you are prescribing. Non-specific answers will not score or will attract a much lower score.
• General answers such as ‘educate’, ‘refer’, ‘reassure’ or ‘review’ do not score without specific detail. For example, providing a review timeline and details about the specialist to whom you are referring (along with degree if urgency, if appropriate) may score marks if relevant to the scenario and question.
• Be aware of clinical guidelines and any important changes or additions to treatments. If guidelines change very close to the exam, the marking keys are adapted to consider the original and the new guidelines so candidates are not penalised if they have not seen a guide published close to the exam sitting.
• Access the practice exams provided after enrolment closes and utilise the RACGP assessment resources provided for candidates.

References

1. https://www.heartfoundation.org.au/images/uploads/publications/PRO-167_Hypertension-guideline-2016_WEB.pdf
2. https://tgldcdp.tg.org.au/viewTopic?topicfile=elevated-blood-pressure&guidelineName=Cardiovascular#toc_d1e389