Page 14 of 15

IM8.{1-8,10-19} | Hypertension — Assignment

CLINICAL SCENARIO

This assignment asks you to prepare a structured clinical case report and comprehensive management plan for a patient with hypertension encountered during your General Medicine clinical posting. You will document the clinical history, perform systematic target organ assessment, select and justify investigations, and construct an evidence-based treatment plan that integrates pharmacological therapy, lifestyle modification, patient counselling, and emergency preparedness. You will also reflect critically on a specific clinical moment during the encounter.

Instructions

Write a structured report in the six sections below using clear, professional clinical language. Use evidence-based references where appropriate (you may cite ACC/AHA 2017 guidelines, JNC 7, KDIGO, or Harrison's Principles of Internal Medicine). Do not copy SDL material verbatim — integrate your own clinical reasoning. Support all drug selections with an explicit rationale. State BP classification systems by name when staging. Word limit: 1,200–1,600 words.

Length: 1,200–1,600 words across all sections

What to Submit

Section 1: Clinical History and BP Classification

Guidance: Document the structured hypertension history using all eight mandatory domains: (1) duration and levels of BP recordings, (2) symptoms of target organ damage and hypertensive crisis (headache, visual change, chest pain, dyspnoea, neurological symptoms), (3) comorbidities (diabetes, CKD, CVD, sleep apnoea), (4) lifestyle factors (salt intake, alcohol, physical activity, sleep, stress), (5) family history and genetic risk, (6) psychosocial and occupational factors, (7) dietary assessment, (8) previous and current antihypertensive therapy with adherence history. Classify the patient's BP according to both ACC/AHA 2017 and JNC 7 — state both classifications explicitly and note where they differ for your patient. Identify any specific feature that makes you consider a secondary cause. Approximately 350 words.

Section 2: Physical Examination and Target Organ Assessment

Guidance: Describe the examination protocol including correct BP measurement technique (position, rest period, cuff size, both arms). For each of the five target organs, document the examination findings and interpretation: (a) Heart — apex beat, added sounds, signs of cardiac failure; (b) Brain — neurological screen, fundoscopy with Keith-Wagener grading; (c) Kidneys — renal angle tenderness, peripheral oedema, urinalysis; (d) Retina — fundoscopic changes graded 1-4; (e) Peripheral vessels — bruits, peripheral pulses, ankle-brachial index if applicable. Describe any secondary cause signs identified on examination. Approximately 300 words.

Section 3: Diagnostic Workup and ECG Interpretation

Guidance: List the mandatory baseline investigations for every hypertensive patient (CBC, urinalysis with microscopy, BUN/creatinine, electrolytes, fasting glucose, lipid profile, ECG) with a specific clinical justification for each. Interpret the ECG provided to you at clinic: state which criterion you are applying (Sokolow-Lyon or Cornell voltage), calculate the voltage sum, and state whether LVH is present. Acknowledge the sensitivity limitation of ECG vs echocardiogram for LVH detection. If your case had features suggesting a secondary cause, describe what additional investigations you requested and why. Approximately 250 words.

Section 4: Treatment Plan — Pharmacological and Lifestyle

Guidance: Using the ACC/AHA 2017 threshold for initiating drug therapy, state whether your patient requires pharmacological treatment now or lifestyle modification first. If drug treatment is indicated: name the specific drug class and first agent with starting dose; state any compelling indication (e.g., CKD with proteinuria, heart failure, post-MI, diabetes) that drives drug selection; outline the titration and combination schedule. Quantify the expected BP reduction from each lifestyle modification you recommend: DASH diet, sodium restriction, aerobic exercise, weight loss, alcohol moderation. Use specific numbers. Approximately 300 words.

Section 5: Hypertensive Emergency Recognition and Patient Counselling

Guidance: Describe the clinical distinction between hypertensive urgency and emergency, defining the role of acute end-organ damage in this distinction. Outline the initial management of a hypertensive emergency: drug of choice (IV agent), target MAP reduction in the first hour (percentage), monitoring required, and when to involve ICU/specialist. For patient counselling: describe how you addressed adherence barriers specific to this patient; what you explained about hypertension's impact on quality of life, work capacity, and family responsibility; and the criteria you would use for specialist referral (nephrologist, cardiologist, endocrinologist). Approximately 250 words.

Section 6: Reflective Learning

Guidance: Reflect on one specific moment during your clinical encounter with this hypertensive patient where your structured learning changed how you communicated with or managed the patient differently from a routine 'check BP and prescribe' encounter. What did you learn that you would not have learned from a textbook alone? Approximately 150 words.

Grading Rubric — Hypertension Case Report and Management Plan Rubric

Criterion	Points	Full-marks descriptor
History and Classification (Section 1): Documents all eight mandatory history domains with appropriate clinical detail; correctly classifies BP using both ACC/AHA 2017 and JNC 7 with explicit citation of which system is used; identifies features suggesting primary vs secondary aetiology.	20 pts	All eight history domains documented with precise clinical detail; BP correctly staged under both ACC/AHA 2017 and JNC 7 with explicit labels; clues for secondary aetiology specifically identified with supporting rationale.
Examination and Target Organ Assessment (Section 2): Describes the full examination protocol for hypertension; identifies and interprets the target organs assessed; correctly interprets fundoscopic and ECG findings for target organ damage.	20 pts	Full BP measurement protocol described (position, arm, rest); target organ examination for all five organs (heart, brain, kidneys, retina, vessels) detailed with specific findings; fundoscopic grading (Keith-Wagener) and ECG LVH interpretation applied correctly.
Diagnostic Workup and ECG Interpretation (Section 3): Selects appropriate investigations with clinical justification; correctly interprets provided ECG for hypertensive changes; understands limitations of ECG vs echocardiogram for LVH detection.	15 pts	All mandatory investigations selected with specific clinical indication for each; ECG interpreted with correct criteria (Sokolow-Lyon or Cornell voltage); limitation of ECG sensitivity acknowledged; additional investigations justified by history.
Treatment Plan — Pharmacological and Lifestyle (Section 4): Constructs an evidence-based pharmacological plan with correct drug class, dose, compelling indication if present, and titration schedule; accurately quantifies lifestyle modification benefits.	25 pts	Drug class selected with correct indication, named first-line drug, dose, and monitoring plan; compelling indication (if applicable) named and linked to specific drug class; lifestyle modifications listed with quantified BP effects; correct use of ACC/AHA threshold for initiating drugs.
Emergency Recognition and Counselling (Section 5): Correctly distinguishes hypertensive urgency from emergency; describes the management algorithm for hypertensive emergency; demonstrates patient-centred counselling with attention to adherence and quality of life.	15 pts	Urgency vs emergency distinction made precisely (with the role of end-organ damage); hypertensive emergency management outlined with correct drug, route, timing, and MAP target; patient counselling addresses adherence barriers, quality of life, and specialist referral criteria.
Reflection (Section 6): Demonstrates genuine critical reflection on a specific clinical encounter; identifies one concrete learning point connecting textbook knowledge to patient-centred management.	5 pts	Reflection is specific and credible; learning point explicitly connects a theory-practice gap to clinical impact on a real or realistic patient.

PEER REVIEW

Review your peer's hypertension case report using the rubric provided. For each criterion, assign a score and write one specific comment explaining your assessment. For Section 1, verify that both ACC/AHA 2017 and JNC 7 classifications are stated with the correct thresholds — note any error if the student uses one system without acknowledging the other. For Section 3, check that the ECG LVH criterion is named and the voltage sum is calculated, not merely asserted. For Section 5, verify that the urgency/emergency distinction is grounded in end-organ damage, not BP level alone. For Section 4, confirm that lifestyle modification benefits are quantified. Complete your review within 72 hours and be specific — do not copy the rubric descriptor as your comment.