Examination for Hypertension-Related Organ Damage
To assess for hypertension-related organ damage, you should examine the cardiovascular system, kidneys, eyes, and neurological system through focused physical examination and targeted laboratory and imaging studies. 1
Physical Examination Components
Cardiovascular Assessment
- Pulse rate, rhythm, and character
- Jugular venous pressure
- Apex beat location and character (to detect left ventricular hypertrophy)
- Heart sounds (including extra heart sounds, murmurs)
- Basal lung crackles (suggesting heart failure)
- Peripheral edema
- Arterial bruits (carotid, abdominal, femoral) 1
- Radio-femoral delay (suggesting aortic coarctation)
Neurological Examination
- Mental status assessment (for subtle confusion)
- Focal neurological deficits (suggesting cerebrovascular damage) 1
Ophthalmologic Examination
- Fundoscopy to detect:
- Retinal changes
- Hemorrhages
- Papilledema
- Arterial tortuosity
- Arteriovenous nipping 1
Other Physical Findings
- Enlarged kidneys (suggesting renal disease)
- Increased BMI/waist circumference (associated risk factors) 1
Laboratory Investigations
Essential Tests
- Serum electrolytes: Sodium, potassium (essential for detecting renal damage and primary aldosteronism)
- Kidney function: Serum creatinine and estimated glomerular filtration rate (eGFR)
- Urinalysis: Dipstick for protein and blood (100% sensitivity for ruling out acute elevation in creatinine) 1
- 12-lead ECG: To detect left ventricular hypertrophy, ischemic heart disease, atrial fibrillation 1
- Lipid profile and fasting glucose: To assess additional cardiovascular risk factors 1
Additional Diagnostic Tests (When Indicated)
Imaging Studies
- Echocardiography: To detect left ventricular hypertrophy, systolic/diastolic dysfunction, atrial dilation 1
- Carotid ultrasound: To identify plaques and stenosis 1
- Renal ultrasound/Doppler: To assess for renal parenchymal disease or renal artery stenosis 1
- Brain CT/MRI: When neurological symptoms are present, to detect ischemic or hemorrhagic brain injury 1
Additional Laboratory Tests
- Urinary albumin/creatinine ratio: To detect early kidney damage 1
- Serum uric acid levels: Elevated in many hypertensive patients and associated with increased cardiovascular risk 1
- Liver function tests: Particularly when metabolic syndrome is suspected 1
Practical Approach
Start with targeted organ assessment:
- Heart (ECG, echocardiography if indicated)
- Kidneys (creatinine, eGFR, urinalysis)
- Eyes (fundoscopic examination)
- Brain (neurological examination)
Prioritize tests based on risk factors:
- For patients >65 years: Focus on cardiovascular and renal assessment
- For patients with diabetes: Emphasize renal and retinal examination
- For patients with symptoms: Direct investigations toward the symptomatic system
Consider additional risk factors that may accelerate organ damage:
Important Caveats
Avoid unnecessary testing: Not all hypertensive patients require comprehensive imaging. A 1978 review found that routine chest radiographs and ECGs rarely influenced hypertensive management 1
Remember regression to the mean: Blood pressure often decreases on repeat measurement without intervention. Consider averaging multiple readings before initiating therapy 1
Focus on evidence of end-organ damage: This determines the urgency and intensity of treatment and may influence the choice of antihypertensive medication 3
Regular monitoring: Patients with evidence of organ damage require closer follow-up and more aggressive treatment targets 2
By systematically examining these organ systems, you can identify hypertension-related damage early and implement appropriate treatment to prevent progression to organ failure and cardiovascular death.