Any elevation in BP is accompanied by increased risk of cardiovascular and cerebrovascular events and renal damage. The most distinctive pathological consequence of untreated hypertension is atherosclerosis. Eventually, in untreated hypertensives, 50 per cent die of coronary heart disease and heart failure, 33 per cent of cerebrovascular events, and 15 per cent of renal failure. It is important to remember that there is no cut off point in hypertension where complications cease to occur. The relationship between BP and risk of hypertensive events is continuous, consistent and independent of other risk factors. In other words, the natural history of untreated hypertension is always bad.
A thorough general and systemic clinical examination is necessary in all cases since important clues to the causation and to the end organ involvement can be obtained.
a)Heart
The complications that occur in the heart due to hypertension are left ventricular hypertrophy,diastolic dysfunction and cardiac failure. There is also associated coronary artery disease. The examination of the heart should be directed to the detection of these findings. The aortic closure sound is accentuated. There may be a heaving apical impulse. Abnormal apex beat, S3 and S4 gallop sounds, loud aortic closure sound (A2). Pulmonary crepitations and elevated JVP denotes heart failure. In the later stages with heart dilatation murmurs of mitral and or tricuspid regurgitation may be heard and there may be a paradoxical split of the second heart sound. ECG can reveal LVH and myocardial ischemia. Echocardiography is one of the most useful methods in the assessment of hypertensive cardiac involvement. The thickness of the left ventricle is increased.
b) Abdomen
The purpose of examining the abdomen should be for detection of renal artery bruit and abnormal kidney masses like kidney tumours and polycystic kidneys. Aortic abdominal aneurysms should be looked for.
c)Pulses
Careful examination of both upper and lower limb pulses is useful in detecting coarctation, and other arterial stenosis. The carotid arteries should be checked for stenosis and bruit.
d)Fundus
A detailed fundus examination would show the changes upon which grading of the intensity of hypertension can be made.
e)General
In general examination, one should look for:
• Oedema: suggestive of heart failure and renal failure.
• Round face, truncal obesity, bufallo hump: in Cushing’s syndrome.
• Obesity, rough skin, bradycardia, puffy face: in myxoedema.
• Tremors, exophthalmos: in thyrotoxicosis.
When to Investigate Further Special investigations should be carried out when features inappropriate for the usual primary hypertension are found to be present.
1) Onset before 20 years
2) BP more than 180/110
3) Organ damage
Grade 2 or above on fundosopy
Serum creatinine >1.5 mg/100 ml
Cardiomegaly on CXR, LVH on ECG
4) Persistent hypokalemia
5) Abdominal bruit
6) Fluctuating BP, especially associated with tachycardia, tremors, sweating.
A thorough general and systemic clinical examination is necessary in all cases since important clues to the causation and to the end organ involvement can be obtained.
a)Heart
The complications that occur in the heart due to hypertension are left ventricular hypertrophy,diastolic dysfunction and cardiac failure. There is also associated coronary artery disease. The examination of the heart should be directed to the detection of these findings. The aortic closure sound is accentuated. There may be a heaving apical impulse. Abnormal apex beat, S3 and S4 gallop sounds, loud aortic closure sound (A2). Pulmonary crepitations and elevated JVP denotes heart failure. In the later stages with heart dilatation murmurs of mitral and or tricuspid regurgitation may be heard and there may be a paradoxical split of the second heart sound. ECG can reveal LVH and myocardial ischemia. Echocardiography is one of the most useful methods in the assessment of hypertensive cardiac involvement. The thickness of the left ventricle is increased.
b) Abdomen
The purpose of examining the abdomen should be for detection of renal artery bruit and abnormal kidney masses like kidney tumours and polycystic kidneys. Aortic abdominal aneurysms should be looked for.
c)Pulses
Careful examination of both upper and lower limb pulses is useful in detecting coarctation, and other arterial stenosis. The carotid arteries should be checked for stenosis and bruit.
d)Fundus
A detailed fundus examination would show the changes upon which grading of the intensity of hypertension can be made.
e)General
In general examination, one should look for:
• Oedema: suggestive of heart failure and renal failure.
• Round face, truncal obesity, bufallo hump: in Cushing’s syndrome.
• Obesity, rough skin, bradycardia, puffy face: in myxoedema.
• Tremors, exophthalmos: in thyrotoxicosis.
When to Investigate Further Special investigations should be carried out when features inappropriate for the usual primary hypertension are found to be present.
1) Onset before 20 years
2) BP more than 180/110
3) Organ damage
Grade 2 or above on fundosopy
Serum creatinine >1.5 mg/100 ml
Cardiomegaly on CXR, LVH on ECG
4) Persistent hypokalemia
5) Abdominal bruit
6) Fluctuating BP, especially associated with tachycardia, tremors, sweating.
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