EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What additional history would you take to assess John’s cardiovascular risk?

• Prompt: What specific lifestyle factors would you inquire about?
• Prompt: How would you explore secondary causes of hypertension?

Q2. What are the possible causes of John’s hypertension, and how would you confirm the diagnosis?

• Prompt: What are the primary and secondary causes of hypertension?
• Prompt: How would you confirm a diagnosis of hypertension?

Q3. Outline your initial management plan, including lifestyle and pharmacological treatment.

• Prompt: What lifestyle modifications would you recommend?
• Prompt: Which antihypertensive medication would you consider and why?

Q4. What are the long-term follow-up and monitoring requirements for John?

• Prompt: How frequently should his blood pressure be monitored?
• Prompt: What screening should be done to monitor for complications?

Q5. John returns in six months with persistent high BP despite lifestyle modifications. What would you do next?

• Prompt: What changes would you make to his treatment?
• Prompt: What additional investigations would you consider?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What additional history would you take to assess John’s cardiovascular risk?

A thorough history-taking is essential to assess John’s cardiovascular risk accurately. Key areas to explore include:

1. Personal Medical History:

• Hypertension symptoms: Any history of dizziness, vision changes, chest pain, palpitations, or shortness of breath.
• Previous BP measurements: Any prior elevated readings or diagnosed hypertension.
• Cardiovascular disease: History of angina, myocardial infarction, stroke, or peripheral vascular disease.
• Metabolic disorders: History of diabetes, dyslipidaemia, or metabolic syndrome.

2. Lifestyle Factors:

• Dietary habits: High salt intake, processed foods, or excessive caffeine.
• Exercise: Type, frequency, and duration of physical activity.
• Stress levels: Psychological stress, workplace demands, and coping mechanisms.
• Smoking history: Pack-year history and readiness for cessation.
• Alcohol consumption: Frequency, quantity, and binge drinking patterns.

3. Family History:

• Cardiovascular diseases: Premature heart disease or stroke in first-degree relatives.
• Diabetes or hypertension: Familial predisposition.

4. Medication and Substance Use:

• Current medications: Any over-the-counter NSAIDs, decongestants, or supplements.
• Recreational drugs: Stimulants (cocaine, amphetamines) that may contribute to hypertension.

5. Secondary Hypertension Screening:

• Sleep apnoea: Snoring, daytime sleepiness, witnessed apnoeas.
• Renal disease: Nocturia, oedema, history of recurrent UTIs.
• Endocrine causes: Symptoms of hyperaldosteronism (muscle cramps, weakness), Cushing’s syndrome (weight gain, moon face), or pheochromocytoma (episodic sweating, tachycardia, headaches).

A comprehensive history will guide risk stratification and inform further investigation or management strategies.

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Q2: What are the possible causes of John’s hypertension, and how would you confirm the diagnosis?

John’s hypertension could be primary (essential hypertension) or secondary due to an underlying condition.

1. Primary Hypertension: Accounts for ~90% of cases. Risk factors include:

• Age >55 years
• Family history
• Lifestyle factors (high salt intake, obesity, alcohol, sedentary lifestyle, smoking)
• Insulin resistance or metabolic syndrome

2. Secondary Hypertension: Must be considered, especially if BP is difficult to control. Possible causes include:

• Renal disease (chronic kidney disease, renal artery stenosis)
• Endocrine disorders (primary aldosteronism, Cushing’s syndrome, pheochromocytoma, thyroid dysfunction)
• Obstructive sleep apnoea
• Drug-induced hypertension (NSAIDs, decongestants, steroids, oral contraceptives)

Confirming the Diagnosis:

• Office BP readings: Repeated on two separate occasions (>140/90 mmHg).
• Ambulatory/home BP monitoring: To exclude white coat hypertension.
• ECG: To assess for left ventricular hypertrophy or ischaemia.
• Blood tests: Renal function, electrolytes (hypokalaemia suggests hyperaldosteronism), lipid profile, fasting glucose/HbA1c.

If secondary hypertension is suspected, targeted investigations (e.g., renal ultrasound, aldosterone-to-renin ratio, sleep studies) may be required.

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Q3: Outline your initial management plan, including lifestyle and pharmacological treatment.

A stepwise approach to management is recommended:

1. Lifestyle Modifications (First-line Intervention):

• Dietary changes: Reduce salt (<4g/day), increase potassium-rich foods (fruits, vegetables), follow the DASH diet.
• Exercise: At least 150 minutes of moderate-intensity activity per week.
• Weight management: Aim for BMI <25 kg/m².
• Smoking cessation: Referral to Quitline, nicotine replacement therapy.
• Alcohol reduction: <2 standard drinks/day.
• Stress management: Mindfulness, relaxation techniques.

2. Pharmacological Management:

• Indications for immediate medication initiation: BP >160/100 mmHg, high cardiovascular risk, end-organ damage.
• First-line medications (based on Australian guidelines):
  • ACE inhibitors (e.g., perindopril) – preferred in younger patients.
  • Calcium channel blockers (e.g., amlodipine) – suitable for older adults.
  • Thiazide diuretics (e.g., indapamide) – for salt-sensitive individuals.
• Monitoring: BP re-evaluation in 4 weeks.

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Q4: What are the long-term follow-up and monitoring requirements for John?

1. Regular BP Monitoring:

• Every 4 weeks initially until BP <140/90 mmHg.
• Every 3-6 months once stable.

2. Cardiovascular Risk Monitoring:

• Annual lipid profile, fasting glucose/HbA1c.
• ECG every 2 years to assess for hypertensive heart disease.

3. Medication Review:

• Monitor for side effects (e.g., hyperkalaemia with ACE inhibitors).
• Adjust therapy if target BP is not achieved.

4. Lifestyle Reinforcement:

• Assess adherence and provide ongoing motivation.

5. Screening for Complications:

• Fundoscopy for hypertensive retinopathy.
• Renal function monitoring.

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Q5: John returns in six months with persistent high BP despite lifestyle modifications. What would you do next?

1. Assess Adherence and Lifestyle:

• Confirm medication adherence.
• Reassess salt intake, exercise, and alcohol consumption.

2. Consider Medication Intensification:

• If already on monotherapy, add a second agent (e.g., ACE inhibitor + calcium channel blocker).
• Consider a triple therapy approach (ACE inhibitor + diuretic + CCB).

3. Investigate Secondary Hypertension:

• Serum aldosterone/renin ratio (for primary aldosteronism).
• Renal ultrasound (for renal artery stenosis).
• Sleep study (for obstructive sleep apnoea).

4. Consider Specialist Referral:

• Resistant hypertension (BP remains >140/90 mmHg on three medications).
• Suspected secondary causes.

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SUMMARY OF A COMPETENT ANSWER

• Comprehensive history-taking covering cardiovascular risks, lifestyle, and secondary causes.
• Thorough assessment of primary vs. secondary hypertension using diagnostic criteria.
• Evidence-based management approach including lifestyle modifications and guideline-directed pharmacotherapy.
• Structured follow-up plan focusing on BP control, cardiovascular risk, and adherence.
• Escalation plan for uncontrolled hypertension, including specialist referral.

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PITFALLS

• Failure to consider secondary hypertension in a patient with persistent high BP.
• Overlooking lifestyle interventions before jumping to medications.
• Not using ambulatory/home BP monitoring to confirm diagnosis.
• Inappropriate medication selection (e.g., beta-blockers first-line in an uncomplicated case).
• Inadequate follow-up plan without assessing treatment response and adherence.

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REFERENCES

• RACGP Guidelines – Hypertension Management
• GP Exams – Hypertension

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and sociocultural context.
1.2 Engages the patient to gather information about their symptoms, concerns, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

…

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD