Hypertension

1. Overview

Hypertension is persistently raised arterial blood pressure. It is one of the most important modifiable risk factors for stroke, myocardial infarction, heart failure, chronic kidney disease, peripheral arterial disease and premature cardiovascular death.

Most adult hypertension is primary hypertension, meaning no single reversible cause is identified. Secondary hypertension should be considered when hypertension is severe, resistant, sudden in onset, occurs at a young age, or is associated with specific clinical features such as hypokalaemia, renal disease, endocrine symptoms or drug exposure.

Key OSCE priorities

• Confirm whether the blood pressure is persistently elevated rather than a single high reading.
• Assess for symptoms of hypertensive emergency or target organ damage.
• Identify cardiovascular risk factors.
• Look for secondary causes of hypertension.
• Assess complications affecting the heart, brain, kidneys, eyes and peripheral vessels.
• Explain lifestyle modification and long-term cardiovascular risk reduction.
• Discuss medication adherence and side effects if the patient is already treated.

Important complications

• Stroke or transient ischaemic attack.
• Myocardial infarction and ischaemic heart disease.
• Heart failure.
• Left ventricular hypertrophy.
• Atrial fibrillation.
• Chronic kidney disease.
• Hypertensive retinopathy.
• Peripheral arterial disease.
• Aortic aneurysm or dissection.

Hypertensive emergency symptoms to ask about

• Chest pain.
• Severe headache.
• Confusion or reduced consciousness.
• Visual disturbance.
• Focal neurological deficit.
• Severe breathlessness or pulmonary oedema.
• Seizure.
• Reduced urine output.
• Pregnancy-related symptoms such as headache, visual symptoms, epigastric pain or swelling.

2. History Taking

Opening

• Wash hands.
• Introduce yourself.
• Confirm patient identity.
• Explain that you would like to ask about their blood pressure and general health.
• Gain consent.
• Check whether the patient currently has chest pain, breathlessness, neurological symptoms, severe headache or visual disturbance.
• If the patient is acutely unwell, state that you would assess using ABCDE and call for senior help.

Presenting complaint

• Ask how the raised blood pressure was discovered.
• Ask whether it was found during routine screening, self-monitoring, clinic visit, emergency visit or pregnancy review.
• Ask what the blood pressure readings were.
• Ask whether readings were repeated.
• Ask whether readings were taken at home, in clinic or with ambulatory monitoring.
• Ask whether the patient has had high blood pressure before.
• Ask whether they are already on treatment.

Symptoms of hypertension and target organ damage

• Headache, especially severe or new headache.
• Visual disturbance.
• Chest pain or pressure.
• Shortness of breath.
• Palpitations.
• Syncope or presyncope.
• Focal weakness, facial droop or speech disturbance.
• Confusion.
• Reduced urine output.
• Leg swelling.
• Claudication.
• Symptoms of heart failure such as orthopnoea or paroxysmal nocturnal dyspnoea.

Hypertensive emergency screen

• Ask about severe headache, confusion, seizures or reduced consciousness.
• Ask about neurological deficit suggesting stroke or TIA.
• Ask about chest pain suggesting ACS or aortic dissection.
• Ask about tearing chest or back pain suggesting aortic dissection.
• Ask about severe breathlessness or frothy sputum suggesting pulmonary oedema.
• Ask about visual loss or severe visual disturbance.
• Ask about reduced urine output suggesting acute kidney injury.
• In pregnant or postpartum patients, ask about headache, visual symptoms, epigastric pain and swelling.

Cardiovascular risk factors

• Smoking.
• Diabetes mellitus.
• Hyperlipidaemia.
• Obesity.
• Physical inactivity.
• Unhealthy diet.
• High salt intake.
• Excess alcohol intake.
• Family history of hypertension or premature cardiovascular disease.
• Chronic kidney disease.
• Previous stroke, TIA, myocardial infarction or peripheral arterial disease.

Secondary hypertension screen

• Young age at onset, especially under 40 years.
• Sudden onset or rapidly worsening hypertension.
• Resistant hypertension despite multiple medications.
• Renal disease symptoms: haematuria, frothy urine, reduced urine output or flank pain.
• Renal artery stenosis clues: worsening renal function after ACE inhibitor or ARB, abdominal bruit, flash pulmonary oedema.
• Obstructive sleep apnoea symptoms: loud snoring, witnessed apnoeas, daytime sleepiness and morning headaches.
• Primary hyperaldosteronism clues: muscle weakness, cramps or hypokalaemia.
• Phaeochromocytoma symptoms: episodic headache, sweating, palpitations and panic-like attacks.
• Cushing syndrome features: weight gain, easy bruising, proximal weakness and purple striae.
• Thyroid symptoms: heat intolerance, tremor, weight loss, fatigue, cold intolerance or weight gain.
• Coarctation clues: hypertension from young age, leg fatigue, weak femoral pulses.

Past medical history

• Known hypertension and duration.
• Diabetes mellitus.
• Chronic kidney disease.
• Stroke or TIA.
• Ischaemic heart disease.
• Heart failure.
• Atrial fibrillation.
• Peripheral arterial disease.
• Obstructive sleep apnoea.
• Endocrine disease.
• Pregnancy-related hypertension or pre-eclampsia.
• Previous hypertensive emergency.

Drug history and allergies

• Current antihypertensive medications and doses.
• Medication adherence.
• Side effects such as dizziness, cough, ankle swelling, electrolyte problems or erectile dysfunction.
• Recent missed doses.
• Over-the-counter medications such as NSAIDs and decongestants.
• Oral contraceptive pill or hormone therapy.
• Steroids.
• Stimulants for ADHD.
• Recreational drugs such as cocaine or amphetamines.
• Liquorice consumption if relevant.
• Herbal or gym supplements.
• Drug allergies and reaction.

Family history

• Hypertension.
• Premature ischaemic heart disease.
• Stroke.
• Chronic kidney disease.
• Sudden cardiac death.
• Endocrine syndromes if suspected.

Social history

• Smoking history.
• Alcohol intake.
• Diet, especially salt intake, processed food and saturated fat.
• Exercise level.
• Weight history.
• Occupation and stress.
• Sleep quality and symptoms of obstructive sleep apnoea.
• Recreational drug use.
• Living situation and support.
• Ability to afford and obtain medications.

Lifestyle assessment

• Salt intake.
• Fruit and vegetable intake.
• Processed food intake.
• Caffeine intake.
• Alcohol quantity and binge drinking.
• Physical activity per week.
• Weight and waist circumference if available.
• Sleep duration and snoring.
• Stress and mental health.

Medication adherence assessment

• Ask how often they miss tablets.
• Ask whether side effects stop them taking medication.
• Ask whether they understand why treatment is needed.
• Ask whether they can afford medication.
• Ask whether the regimen is too complex.
• Ask whether they use reminders or pill boxes.
• Avoid blaming language; use a supportive tone.

Ideas, concerns and expectations

• Ask what the patient thinks caused the high blood pressure.
• Ask what they are most worried about, such as stroke or heart attack.
• Ask what they know about hypertension.
• Ask what they were hoping would happen today.
• Explore concerns about lifelong medication.

Red flags

• Severe blood pressure elevation with chest pain.
• Severe blood pressure elevation with neurological symptoms.
• Severe headache, confusion, seizure or reduced consciousness.
• Visual loss or papilloedema.
• Acute breathlessness or pulmonary oedema.
• Reduced urine output or acute kidney injury.
• Pregnancy or postpartum hypertension with symptoms.
• Suspected aortic dissection.
• Very young patient with severe hypertension.
• Resistant hypertension despite multiple drugs.

Closing the history

• Summarise the key points back to the patient.
• Ask if they would like to add anything else.
• Thank the patient.
• State that you would measure blood pressure properly, assess cardiovascular risk, examine for complications and arrange investigations.

3. Physical Examination

The examination should confirm blood pressure measurement, assess for target organ damage, look for cardiovascular risk and screen for secondary causes of hypertension.

Before starting the examination

• Wash hands or use alcohol gel.
• Introduce yourself with name and role.
• Confirm the patient's identity.
• Explain the examination clearly.
• Gain consent.
• Ask if the patient has chest pain, breathlessness, headache, dizziness or visual symptoms.
• Position the patient comfortably.
• Ensure adequate exposure while maintaining dignity.
• Ask for a chaperone if appropriate.

General inspection

• Assess whether the patient looks well or acutely unwell.
• Look for obesity or central adiposity.
• Look for signs of distress, breathlessness, confusion or neurological deficit.
• Look for Cushingoid features such as central obesity, facial rounding and bruising.
• Look for acromegalic features if clinically suspected.
• Look for oxygen, cardiac monitor, IV lines or emergency treatment if inpatient.

Correct blood pressure measurement

• Ensure the patient is rested and seated comfortably.
• Use an appropriately sized cuff.
• Support the arm at heart level.
• Measure blood pressure in both arms initially.
• Use the arm with the higher reading for subsequent measurements.
• Repeat the reading if elevated.
• Measure standing blood pressure if postural symptoms, diabetes, older age or autonomic dysfunction are present.
• Consider home or ambulatory blood pressure monitoring to confirm diagnosis when appropriate.

Vital signs

• Blood pressure.
• Pulse rate.
• Pulse rhythm.
• Respiratory rate.
• Oxygen saturation.
• Temperature if infection or acute illness is suspected.
• Weight and BMI.
• Waist circumference if part of cardiovascular risk assessment.

Hands

• Look for peripheral cyanosis.
• Check capillary refill time.
• Look for nicotine staining.
• Look for clubbing if chronic cardiopulmonary disease is suspected.
• Look for palmar erythema or bruising if endocrine or systemic disease is suspected.
• Assess for tremor suggesting thyrotoxicosis or anxiety.
• Check for peripheral oedema.

Pulse examination

• Assess radial pulse rate.
• Assess rhythm.
• An irregularly irregular pulse may suggest atrial fibrillation.
• Assess pulse volume.
• Check radio-radial delay if vascular disease is suspected.
• Check radio-femoral delay if coarctation is suspected.
• Palpate peripheral pulses if peripheral arterial disease is suspected.

Face and eyes

• Look for conjunctival pallor suggesting anaemia or chronic disease.
• Look for xanthelasma and corneal arcus suggesting dyslipidaemia.
• Look for features of thyrotoxicosis such as lid lag or lid retraction.
• Ask whether formal fundoscopy has been performed.
• If competent and equipment is available, perform fundoscopy for hypertensive retinopathy.
• Look for papilloedema, retinal haemorrhages or cotton wool spots in severe hypertension.

Neck

• Assess jugular venous pressure.
• Raised JVP may suggest heart failure or fluid overload.
• Assess carotid pulse if appropriate.
• Auscultate for carotid bruits if vascular disease is suspected.
• Inspect and palpate the thyroid if thyroid disease is suspected.
• Listen for thyroid bruit if Graves disease is suspected.

Cardiovascular examination

• Inspect the chest for scars, pacemaker or visible pulsations.
• Palpate the apex beat.
• A displaced apex beat may suggest left ventricular hypertrophy or cardiomegaly.
• Palpate for heaves and thrills.
• Auscultate the aortic, pulmonary, tricuspid and mitral areas.
• Listen for murmurs, including aortic stenosis or renal-related flow murmurs if relevant.
• Listen for fourth heart sound if hypertensive heart disease is suspected.
• Listen for signs of heart failure such as S3.

Respiratory examination

• Assess respiratory rate and work of breathing.
• Auscultate lung bases for crackles suggesting heart failure or pulmonary oedema.
• Assess for pleural effusion if fluid overload is suspected.
• Look for signs of obstructive sleep apnoea risk such as obesity and large neck circumference.

Abdominal examination

• Inspect the abdomen for central obesity, scars and striae.
• Palpate for enlarged kidneys if polycystic kidney disease is suspected.
• Palpate for abdominal masses.
• Palpate for hepatomegaly if heart failure or liver disease is suspected.
• Auscultate for renal bruits suggesting renal artery stenosis.
• Auscultate for abdominal aortic bruit if vascular disease is suspected.
• Assess for abdominal aortic aneurysm if clinically relevant.

Peripheral vascular examination

• Check peripheral pulses.
• Assess for radio-femoral delay if coarctation is suspected.
• Check for femoral bruits if vascular disease is suspected.
• Look for peripheral arterial disease signs such as cool limbs, hair loss, ulcers or reduced pulses.
• Check for peripheral oedema.

Neurological examination if indicated

• Assess consciousness level if acutely unwell.
• Check speech, facial symmetry and limb power if stroke or TIA is suspected.
• Assess visual fields if neurological symptoms are present.
• Assess gait if safe and relevant.
• Perform a focused neurological examination if headache, confusion or focal symptoms are present.

Signs suggesting secondary causes

• Renal bruits suggesting renal artery stenosis.
• Enlarged kidneys suggesting polycystic kidney disease.
• Hypokalaemia features such as weakness may suggest hyperaldosteronism.
• Thyroid signs suggesting hyperthyroidism or hypothyroidism.
• Cushingoid features such as striae, bruising, proximal weakness and central obesity.
• Radio-femoral delay suggesting coarctation of the aorta.
• Features of obstructive sleep apnoea such as obesity, large neck and daytime sleepiness.

Specific findings to mention in hypertension OSCE

• Blood pressure should be repeated and confirmed properly.
• Look for hypertensive retinopathy.
• Look for left ventricular hypertrophy or heart failure.
• Look for chronic kidney disease signs.
• Look for peripheral arterial disease.
• Look for secondary causes if young, severe or resistant hypertension.
• A normal examination does not exclude hypertension-related risk.

To complete the examination

To complete my examination, I would confirm blood pressure with appropriate repeated clinic measurements and out-of-office monitoring where indicated, assess cardiovascular risk, check urine dip, request blood tests including renal function and electrolytes, perform ECG, consider fundoscopy, and arrange further investigation for secondary causes if suggested by the history or examination.

4. Differential Diagnosis

Primary hypertension

• Most common cause of hypertension in adults.
• Associated with age, family history, obesity, high salt intake, alcohol, physical inactivity and metabolic risk factors.
• Usually develops gradually and may be asymptomatic.

Renal causes

• Chronic kidney disease.
• Renal artery stenosis.
• Polycystic kidney disease.
• Glomerulonephritis.
• Reflux nephropathy.

Endocrine causes

• Primary hyperaldosteronism.
• Phaeochromocytoma.
• Cushing syndrome.
• Hyperthyroidism.
• Hypothyroidism.
• Acromegaly.
• Hyperparathyroidism.

Cardiovascular causes

• Coarctation of the aorta.
• Aortic stiffness in older adults.
• Raised intracranial pressure in rare acute settings.

Drug and lifestyle causes

• NSAIDs.
• Steroids.
• Combined oral contraceptive pill.
• Sympathomimetics and decongestants.
• Stimulants for ADHD.
• Cocaine or amphetamines.
• Excess alcohol.
• High salt intake.
• Liquorice.
• Obstructive sleep apnoea.

White coat and masked hypertension

• White coat hypertension: raised clinic BP but normal home or ambulatory readings.
• Masked hypertension: normal clinic BP but raised home or ambulatory readings.
• Out-of-office monitoring helps clarify the diagnosis.

5. Investigations

Confirming hypertension

• Repeat clinic blood pressure measurements.
• Measure blood pressure in both arms initially.
• Use ambulatory blood pressure monitoring where available to confirm diagnosis.
• Use home blood pressure monitoring if ambulatory monitoring is not available or not tolerated.
• Assess for white coat effect or masked hypertension when suspected.
• Standing blood pressure should be checked when postural hypotension is suspected or in higher-risk groups.

Bedside tests

• Urine dipstick for protein, blood and glucose.
• Weight and BMI.
• Waist circumference if appropriate.
• Full cardiovascular observations.
• ECG to assess left ventricular hypertrophy, ischaemia or arrhythmia.
• Fundoscopy if severe hypertension or symptoms suggest retinopathy.

Blood tests

• Urea and electrolytes.
• Creatinine and estimated GFR.
• Potassium, especially before and after renin-angiotensin system blockers or diuretics.
• Fasting glucose or HbA1c.
• Lipid profile.
• Full blood count if anaemia, renal disease or systemic disease is suspected.
• Calcium if endocrine cause is suspected.
• Thyroid function tests if thyroid disease is suspected.

Urine tests

• Urine albumin-to-creatinine ratio.
• Urine protein if kidney disease is suspected.
• Urine microscopy if haematuria or renal disease is suspected.

Assessment for target organ damage

• ECG for left ventricular hypertrophy, ischaemia or atrial fibrillation.
• Urine ACR for kidney damage.
• Renal function and eGFR.
• Fundoscopy for hypertensive retinopathy.
• Echocardiogram if heart failure, murmur or LVH assessment is needed.

Secondary hypertension investigations if indicated

• Renin and aldosterone ratio for suspected primary hyperaldosteronism.
• Renal ultrasound for kidney disease or structural abnormality.
• Renal artery imaging if renal artery stenosis is suspected.
• Plasma or urinary metanephrines if phaeochromocytoma is suspected.
• Cortisol testing if Cushing syndrome is suspected.
• Sleep study if obstructive sleep apnoea is suspected.
• Specialist referral for young, severe or resistant hypertension.

Important investigation points

• Do not diagnose chronic hypertension from a single mildly elevated reading.
• Severe hypertension with symptoms or target organ damage needs urgent same-day assessment.
• Out-of-office readings help confirm true persistent hypertension.
• Investigations should assess both cause and complications.
• Always check renal function and electrolytes when starting or adjusting many antihypertensive drugs.

6. Management

Management depends on blood pressure severity, cardiovascular risk, target organ damage, age, comorbidities, pregnancy status and whether there is suspected secondary hypertension or hypertensive emergency.

Immediate approach if severe or symptomatic

1. Assess ABCDE if acutely unwell.
2. Check for symptoms of hypertensive emergency.
3. Repeat blood pressure using correct technique.
4. Look for target organ damage: neurological deficit, chest pain, pulmonary oedema, acute kidney injury or retinopathy.
5. Call for senior help if hypertensive emergency is suspected.
6. Do not rapidly lower blood pressure without senior guidance unless following an emergency protocol.
7. Manage according to local emergency or specialty pathway.

Lifestyle management

• Reduce salt intake.
• Adopt a healthy diet rich in fruit, vegetables and low-fat foods.
• Lose weight if overweight or obese.
• Increase regular physical activity.
• Stop smoking.
• Reduce alcohol intake.
• Limit excessive caffeine if contributing.
• Improve sleep and assess for obstructive sleep apnoea if suspected.
• Manage stress where relevant.

Medication principles

• Medication choice depends on age, ethnicity, comorbidities, side-effect profile, pregnancy potential and local guidance.
• Common first-line options include ACE inhibitors, ARBs and calcium channel blockers.
• Thiazide-like diuretics are often used as add-on or alternative therapy.
• Beta-blockers may be used when there is another indication such as angina, previous MI, heart failure, arrhythmia or pregnancy-related considerations depending on protocol.
• Avoid ACE inhibitors and ARBs in pregnancy.
• Check renal function and potassium after starting or increasing ACE inhibitors, ARBs, ARNIs, mineralocorticoid receptor antagonists or diuretics.
• Simplify the regimen where possible to improve adherence.

Common medication side effects to counsel about

• ACE inhibitors: cough, hyperkalaemia, renal function change and rare angioedema.
• ARBs: hyperkalaemia and renal function change, usually less cough than ACE inhibitors.
• Calcium channel blockers: ankle swelling, flushing, headache and constipation.
• Thiazide-like diuretics: electrolyte disturbance, gout, dehydration and increased urination.
• Beta-blockers: bradycardia, fatigue, cold peripheries and bronchospasm risk in susceptible patients.
• Alpha-blockers: postural hypotension and dizziness.
• Spironolactone: hyperkalaemia, renal function change and gynaecomastia.

Resistant hypertension

• Check adherence before labelling resistant hypertension.
• Confirm readings with home or ambulatory monitoring.
• Review lifestyle factors including salt, alcohol, obesity and sleep apnoea.
• Review interfering drugs such as NSAIDs, steroids and stimulants.
• Check renal function and electrolytes.
• Consider secondary causes.
• Specialist input may be required.

Monitoring and follow-up

• Agree an individualized blood pressure target according to age, comorbidities and local guidance.
• Review blood pressure after lifestyle changes and medication initiation or adjustment.
• Monitor renal function and electrolytes after relevant medication changes.
• Assess side effects and adherence.
• Review global cardiovascular risk.
• Repeat urine ACR and renal function according to risk and local protocol.
• Encourage home blood pressure monitoring if appropriate and validated device is available.

Patient counselling points

• Hypertension is often asymptomatic but increases long-term cardiovascular risk.
• Treatment reduces risk of stroke, heart attack, heart failure and kidney disease.
• Lifestyle changes and medication work together.
• Do not stop medication suddenly without medical advice.
• Take medication at the same time each day.
• Report troublesome side effects rather than stopping treatment.
• Seek urgent help for chest pain, severe breathlessness, neurological symptoms, severe headache, visual loss or collapse.

7. Examiner Questions

1. What is hypertension?
2. Why is hypertension important?
3. How do you confirm a diagnosis of hypertension?
4. What is white coat hypertension?
5. What is masked hypertension?
6. What are the complications of hypertension?
7. What symptoms suggest hypertensive emergency?
8. What are the causes of secondary hypertension?
9. What investigations would you request?
10. Why do you check urine ACR?
11. Why is ECG useful in hypertension?
12. What lifestyle advice would you give?
13. What drug classes are used to treat hypertension?
14. What side effects can ACE inhibitors cause?
15. When would you suspect resistant hypertension?
16. When would you refer to a specialist?

Suggested short answers

8. OSCE Pearls

• Do not diagnose chronic hypertension from one mildly elevated clinic reading.
• Always ask about symptoms of hypertensive emergency.
• Always assess cardiovascular risk factors.
• Ask about kidney disease and urine symptoms.
• Ask about drug causes: NSAIDs, steroids, OCP, stimulants, cocaine and decongestants.
• Ask about obstructive sleep apnoea symptoms.
• Young, severe or resistant hypertension should make you think of secondary causes.
• Measure blood pressure properly with the correct cuff size.
• Measure both arms initially.
• Check standing blood pressure when postural symptoms or higher-risk features are present.
• Urine dip, renal function, electrolytes, lipid profile, HbA1c and ECG are high-yield investigations.
• Lifestyle advice is not optional; it is central to management.
• Medication adherence is a common reason for poor control.
• Always safety-net for chest pain, neurological symptoms, severe headache, visual symptoms or breathlessness.

9. Example Presentation to Examiner

10. References

• NICE NG136: Hypertension in adults: diagnosis and management.
• 2024 ESC Guidelines for the management of elevated blood pressure and hypertension.
• NICE Clinical Knowledge Summary: Hypertension.
• Local primary care, cardiology and emergency medicine protocols.
• Standard undergraduate clinical examination and OSCE teaching resources.