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HYPERTENSION: DIAGNOSISCheck blood pressure (BP)• Seat patient with arm supported at heart level for 5 minutes.• Use a standard cuff or larger cuff if mid-upper arm circumference is > 33cm.• Record systolic BP (SBP) and diastolic BP (DBP): SBP is the first appearance of sound. DBP is the disappearance of sound.• If raised, recheck until a reading is repeated. Use this reading to determine the patient’s BP.• Do not diagnose hypertension on the basis of one reading alone.< 180/110• If patient has diabetes diagnose hypertension if BP > 140/80 on 2 days 71.• Is there ischaemic heart disease, peripheral vascular disease, stroke, heart failure or kidney disease?No< 140/90 140/90–179/109130/80–179/109< 130/80Yes≥ 180/110Does patient have any of the following: headache,difficult breathing, visual disturbances, chest pain,confusion, leg swelling?NoYes• Review in5 years ifall readingsnormal.• Review in1 year ifany raisedreadings.Check BP on 2 further occasions at least2 days apart.140/90–159/99Assess CVD risk 68.Is CVD risk > 20%?NoPatient is at risk forhypertension.• Manage patient’s CVDrisk 69.• Recheck BP in 3 months.< 140/90 ≥ 140/90Yes160/100–179/109Check BP on 2further occasionsat least 2 daysapart.BP confirmed130/80–179/109Repeat BP atroutine care visits.• Diagnosehypertension.• Start routinehypertensioncare 74.• Start drugtreatment atstep 1 andstep 2 anti–hypertensivetreatment 74.• Review in 2weeks.Patient needs urgent care• Only treat BP if no sign ofstroke: sudden onset ofweakness on 1 or both sides,vision problems, dizziness,difficulty speaking orswallowing.• Give amlodipine 10mg orallystat. If unavailable, giveenalapril 10mg orally stat.• Avoid short-actingnifedipine as it may dropthe BP too quickly, causinga stroke.• If dizzy or faint aftertreatment, check BP: ifmore than 25% drop or< 160/100, lie patient downwith legs raised.• Refer same day to hospital.• Continue CVD riskmanagement 69.• Check BP in 1 year.• Diagnose hypertension. Do not diagnose hypertensionon the basis of one reading alone.• Start routine hypertension care 74.• Refer if patient is < 30 years or pregnant.73
HYPERTENSION: ROUTINE CAREAssess the patient with hypertensionAssess When to assess NoteSymptoms Every visit Manage symptoms on symptom page. Ask about symptoms of stroke or transient ischaemic attack (TIA).BP Every visit BP is controlled if < 140/90 (or 120/70–140/80 if diabetes, or 25, calculate target weight: 25 x height (m) x height (m).Waist circumference At diagnosis, yearly or 3 monthly if trying to lose weight Aim for < 80cm (woman), < 94cm (man).CVD risk At diagnosis and every 5 years If CVD or diabetes no need to check. It reflects the risk of a heart attack or stroke over the next 10 years 68.Glucose Yearly and if glucose on urine dipstick Check random finger-prick glucose 70 to interpret result. Check every visit if patient diabetic.eGFR Yearly Estimated glomerular filtration rate reflects kidney function. Give age and sex on form. If < 60 refer to doctor.Urine dipstick Yearly Refer to doctor if blood or protein on repeat dipstick. If glucose on dipstick, screen for diabetes 70.Cholesterol At diagnosis Refer to specialist if total cholesterol ≥ 7.5.If patient on treatment, check if BP is controlled: < 140/90 (or 120/70–140/80 if diabetes, or 20%. Avoid in pregnancy, liver disease.• Give aspirin 150mg daily if patient has CVD and/or diabetes. Avoid if < 30 years, previous peptic ulcers or dyspepsia or if BP ≥ 180/110.• Treat hypertension stepwise as in table below along with CVD risk management 69. If BP is not controlled after 1 month on treatment and patient is adherent, proceed to the following step:Step Drugs all once a day Note1 Start hydrochlorothiazide (HCTZ) 12.5mg Avoid in pregnancy (refer), liver or kidney disease, gout. Use enalapril first instead in diabetes, kidney disease, heart failure.2 Add enalapril 10mg Avoid/stop in pregnancy, angioedema or renal artery stenosis: use amlodipine 5mg daily instead. If eGFR < 60 and/or peripheral vascular disease,check eGFR and potassium within 4 weeks of starting/changing dose.3 Add amlodipine 5mg and increase enalapril to 20mg. Avoid amlodipine in heart failure if possible.4 Add atenolol 50mg; increase HCTZ to 25mg and amlodipine to 10mg. Avoid atenolol in pregnancy, asthma, COPD, heart failure. Refer for specialist assessment if BP not controlled on step 4 treatment.CHRONIC DISEASESOF LIFESTYLE74
- Page 28 and 29: GENITAL SYMPTOMSAssess the patient
- Page 30 and 31: VAGINAL DISCHARGE• It is normal f
- Page 32 and 33: OTHER GENITAL SYMPTOMSFirst assess
- Page 34 and 35: ABNORMAL VAGINAL BLEEDING• BP < 9
- Page 36 and 37: URINARY SYMPTOMSRecognise patient w
- Page 38 and 39: JOINT SYMPTOMSRecognise the patient
- Page 40 and 41: NECK PAINRecognise the patient with
- Page 42 and 43: FOOT SYMPTOMS• If the problem is
- Page 44 and 45: BURNSAttend urgently to the patient
- Page 46 and 47: PAINFUL SKINFirm, red lump which so
- Page 48 and 49: GENERALISED ITCHY RASHIf status unk
- Page 50 and 51: GENERALISED NON ITCHY RED RASHIs pa
- Page 52 and 53: CHANGES IN SKIN COLOURYellow skinDa
- Page 54 and 55: SUICIDAL PatientRecognise the patie
- Page 56 and 57: CONFUSED Patient• The confused pa
- Page 58 and 59: TRAUMATISED/ABUSED PatientRecognize
- Page 60 and 61: TB: DIAGNOSISExclude TB in the pati
- Page 62 and 63: TB: ROUTINE CAREAssess the patient
- Page 64 and 65: Manage the patient with a positive
- Page 66 and 67: HIV: ROUTINE CAREAssess the patient
- Page 68 and 69: Advise the patient with HIV• Supp
- Page 70 and 71: ASTHMA AND COPD: DIAGNOSIS• The p
- Page 72 and 73: CHRONIC OBSTRUCTIVE PULMONARY DISEA
- Page 74 and 75: CARDIOVASCULAR DISEASE (CVD) RISK:
- Page 76 and 77: DIABETES: ROUTINE CAREAssess the pa
- Page 80 and 81: HEART FAILURE: ROUTINE CARE• The
- Page 82 and 83: ISCHAEMIC HEART DISEASE (IHD): DIAG
- Page 84 and 85: PERIPHERAL VASCULAR DISEASE (PVD)
- Page 86 and 87: DEPRESSION AND ANXIETY: DIAGNOSISAs
- Page 88 and 89: SUBSTANCE ABUSEIdentify the patient
- Page 90 and 91: Advise the patient with psychosis
- Page 92 and 93: EPILEPSYDr• If the patient is fit
- Page 94 and 95: GOUT• Gout is a metabolic disease
- Page 96 and 97: CONTRACEPTIONGive emergency contrac
- Page 98 and 99: THE PREGNANT Patient• Fitting•
- Page 100 and 101: ROUTINE ANTENATAL CAREAssess the pr
- Page 102 and 103: POSTNATAL CAREAssess the mother and
- Page 104 and 105: PREP ROOM ASSESSMENT OF THE Patient
- Page 106 and 107: CVD RISKRoutine care summaryDIABETE
- Page 108: 103TB HIV CHRONIC RESPIRATORYDISEAS
HYPERTENSION: ROUTINE CAREAssess the patient with hypertensionAssess When to assess NoteSymptoms Every visit Manage symptoms on symptom page. Ask about symptoms of stroke or transient ischaemic attack (TIA).BP Every visit BP is controlled if < 140/90 (or 120/70–140/80 if diabetes, or 25, calculate target weight: 25 x height (m) x height (m).Waist circumference At diagnosis, yearly or 3 monthly if trying to lose weight Aim for < 80cm (woman), < 94cm (man).CVD risk At diagnosis and every 5 years If CVD or diabetes no need to check. It reflects the risk of a heart attack or stroke over the next 10 years 68.Glucose Yearly and if glucose on urine dipstick Check random finger-prick glucose 70 to interpret result. Check every visit if patient diabetic.eGFR Yearly Estimated glomerular filtration rate reflects kidney function. Give age and sex on form. If < 60 refer to doctor.Urine dipstick Yearly Refer to doctor if blood or protein on repeat dipstick. If glucose on dipstick, screen for diabetes 70.Cholesterol At diagnosis Refer to specialist if total cholesterol ≥ 7.5.If patient on treatment, check if BP is controlled: < 140/90 (or 120/70–140/80 if diabetes, or 20%. Avoid in pregnancy, liver disease.• Give aspirin 150mg daily if patient has CVD and/or diabetes. Avoid if < 30 years, previous peptic ulcers or dyspepsia or if BP ≥ 180/110.• Treat hypertension stepwise as in table below along with CVD risk management 69. If BP is not controlled after 1 month on treatment and patient is adherent, proceed to the following step:Step Drugs all once a day Note1 Start hydrochlorothiazide (HCTZ) 12.5mg Avoid in pregnancy (refer), liver or kidney disease, gout. Use enalapril first instead in diabetes, kidney disease, heart failure.2 Add enalapril 10mg Avoid/stop in pregnancy, angioedema or renal artery stenosis: use amlodipine 5mg daily instead. If eGFR < 60 and/or peripheral vascular disease,check eGFR and potassium within 4 weeks of starting/changing dose.3 Add amlodipine 5mg and increase enalapril to 20mg. Avoid amlodipine in heart failure if possible.4 Add atenolol 50mg; increase HCTZ to 25mg and amlodipine to 10mg. Avoid atenolol in pregnancy, asthma, COPD, heart failure. Refer for specialist assessment if BP not controlled on step 4 treatment.CHRONIC DISEASESOF LIFESTYLE74
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