Her lungs were clear bilaterally without adventitious sounds. Her weight was 151.3 lb, height was 62.5 in, and body mass index was 27.1 (calculated as weight in kilograms divided by height in meters squared). On examination, her systolic BP in both arms with an adult cuff was 184 mm Hg at the onset of Korotkoff sounds, which ceased at 162 mm Hg after a period of silence, sounds reappeared at a systolic BP of 140 mm Hg. She is interested in better BP control to prevent a stroke. She is active, walking as part of a senior program in her neighborhood daily. Ms H is a lifetime nonsmoker and drinks alcohol rarely. Her medical history is notable for removal of a right eye cataract in 2004 and glaucoma for which she uses timolol 0.5% eye drops twice per day and latanoprost 0.005% eye drops once per day at bedtime. Her creatinine began to increase 9 months prior, rising from a stable baseline of 0.9 mg/dL to 1.4 mg/dL when most recently checked. Her echocardiogram 10 months prior showed mild symmetric left ventricular hypertrophy with normal systolic function (left ventricular ejection fraction of 70%). In addition, at a routine visit in the past year, the nurse practitioner who has cared for her for more than 20 years noted an auscultatory gap in systolic BP between 150 and 120 mm Hg. Spironolactone was added to her regimen recently however, her systolic BP decreased to 107 to 110 mm Hg and she reported dizziness. ![]() Despite the 4-drug regimen, Ms H’s systolic BP has ranged from 146 to 196 mm Hg and her diastolic BP from 82 to 92 mm Hg, with 1 systolic value as high as 202 mm Hg. Over the past year, her BP has fluctuated and her current regimen now include samlodipine, 5 mg/d atenolol, 75 mg/d chlorthalidone, 25 mg/d andlisinopril, 40 mg/d. For more than 20 years, her blood pressure (BP) was reasonably controlled with hydrochlorothiazide, 25 mg/d. ![]() ![]() Dr Burns Ms H is a 91-year-old African American woman with difficult-to-control hypertension.
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