How high blood pressure is evaluated

One of the commonest ways for high blood pressure to be detected is on a routine physical examination, for example for health insurance. If you are told that you have high blood pressure, you will probably be referred for further evaluation, either by your own doctor, or by a specialist. The purpose of this evaluation, or work-up, as it's commonly called, is to answer the following questions:

• How high is the pressure?
• What's causing it to go up?
• Has it caused any damage?
• How should it be treated?

Finding the answers to these questions may take a number of visits and several tests, but it's definitely a worthwhile procedure, because high blood pressure is generally a life-long condition, and you don't want to be prescribed medication unnecessarily, which is not an uncommon event.

What To Expect At Your First Visit

The History

When you first see your doctor, he or she will conduct a full history and physical examination. You'll probably be asked to describe any symptoms you've had, and how it was first learned that your pressure was up. If you've been feeling perfectly well all along, and have no symptoms to report, don't worry - that's the norm. Your doctor will want to know what level of pressure you've had over the years - when you had previous physical exams, for example, or if you're a woman, how high it was during pregnancy. In most people blood pressure tends to go up gradually with age, but if your pressure has always been normal and suddenly goes to very high levels over a period of six months to a year, it has a very different significance than if it takes many years to reach the same level. This may be a clue to an underlying problem with a kidney or adrenal gland.

You'll also be asked about medications you've taken, including both prescribed and over-the-counter medicines. If you've had high blood pressure for some time, and have taken blood pressure lowering medications, it's helpful to know whether they did actually lower your pressure (not all medicines work in all patients), and whether you had side effects.

Questions about other symptoms and problems will be directed to providing more clues both to the cause and the consequences of the high blood pressure. If, for example, you've experienced episodes of headaches, sweating, and going white in the face, it could be an indication that your hypertension is due to an extremely rare tumor of the adrenal gland (called a pheochromocytoma). And if you've begun to get a tight feeling in the chest when you climb a flight of stairs, it may be a sign that the hypertension has affected your heart.

One of the most important determinants of blood pressure is heredity. If one of your parents had high blood pressure, your chance of having it is increased, and if both did, it will be even higher. You'll certainly be asked about your parents' health, therefore. There will also be questions about your lifestyle: if you drink a lot of alcohol, this may raise your blood pressure, and if you smoke, this will definitely raise the risk of heart disease (as well as many other diseases). Your diet and exercise habits will also be evaluated.

The Physical Exam

The physical exam will also focus on the evaluation of the causes and consequences of hypertension. Your doctor will probably take several readings of your blood pressure, from both arms, and in different positions: Lying, sitting, and standing. Many patients are very anxious at this point, which tends to make their blood pressure go up. It often takes several visits to get an idea of what the blood pressure really is.

Your doctor will examine your heart to see if it is enlarged or if there are murmurs (sounds made by the blood going through a narrowed or leaky heart valve), and your lungs to see if there is any sign of congestion. He/she may examine the pulses in your neck (the carotid arteries) and other parts of your body. The blood usually flows silently, but if there is a partial blockage there may be a whooshing sound (called a bruit- the French word for noise).

Examination of the abdomen may show enlarged kidneys, or a bruit over the renal (kidney) arteries. This is a clue to the presence of a blocked renal artery (renal artery stenosis), which is a cause of hypertension in both young and old people. Another relevant finding may be an enlarged aorta (the main artery of the body), which occasionally may balloon out to form an aneurysm.

An important part of the physical exam is the eyes. By shining a light into the eyes, using a device called an ophthalmoscope, it is possible to see the small arteries and veins that run across the surface of the retina (the cells at the back of the eye that enable us to see). If the hypertension is severe, the arteries become thicker, and if things get even worse, the arteries start to leak, and there may be yellow patches on the retina (which normally looks pink) called exudates. They may also burst and leak blood, which shows up as little red blobs on the retina.

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