What is the approach to taking a medical history in a patient with primary hypertension?

History Taking in Primary Hypertension

When evaluating a patient with suspected primary hypertension, obtain a structured history focusing on blood pressure patterns, cardiovascular risk factors, symptoms suggesting secondary causes or complications, and family history—this systematic approach identifies patients requiring further investigation while establishing baseline cardiovascular risk.

Blood Pressure History

• Document the duration of hypertension, previous BP levels, and any prior antihypertensive medications including reasons for discontinuation or intolerance 1
• Inquire about current medications and over-the-counter drugs that can elevate BP, including NSAIDs, decongestants, oral contraceptives, and corticosteroids 1
• Ask about adherence to previous antihypertensive treatment, as non-compliance is more common than true resistant hypertension 2

Cardiovascular Risk Factor Assessment

• Personal history: Document myocardial infarction, heart failure, stroke, transient ischemic attacks, diabetes, dyslipidemia, chronic kidney disease, and smoking status 1
• Lifestyle factors: Assess dietary sodium intake (including processed and fast foods), alcohol consumption (quantify drinks per week), physical activity level, and recent weight changes 1
• Family history: Record hypertension and premature cardiovascular disease in first-degree relatives, as this is a major predictor of essential hypertension 1, 3

The presence of lifestyle factors favoring higher BP—such as weight gain, high-sodium diet, decreased physical activity, job changes with increased stress, or excessive alcohol consumption—supports primary hypertension 1. A gradual increase in BP with slow rate of rise also suggests essential hypertension 1.

Symptoms Suggesting Secondary Hypertension

While most hypertensive patients are asymptomatic, specific symptoms warrant investigation for secondary causes 1:

• Endocrine causes: Muscle weakness, tetany, cramps, or arrhythmias suggest hypokalemia from primary aldosteronism; sweating, palpitations, and frequent headaches suggest pheochromocytoma 1
• Renal disease: Flash pulmonary edema suggests renal artery stenosis; hematuria, nocturia, or history of urinary tract infections suggest renal parenchymal disease 1
• Sleep apnea: Snoring and daytime sleepiness indicate obstructive sleep apnea 1
• Other: Weight loss, palpitations, and heat intolerance suggest hyperthyroidism; central obesity, facial rounding, and easy bruising suggest Cushing's syndrome 1

Symptoms of Target Organ Damage

Assess for complications that may already be present 1:

• Cardiac: Chest pain, shortness of breath, palpitations, peripheral edema
• Vascular: Claudication, cold extremities
• Neurologic: Headaches (especially occipital), blurred vision, dizziness, history of stroke or TIA
• Renal: Nocturia, hematuria

Perinatal and Developmental History

In younger patients, obtain perinatal information including maternal hypertension during pregnancy, gestational age, birth weight, and neonatal complications, as low birth weight is associated with later hypertension 1.

Psychosocial History

Document stress, depression, anxiety, and adverse childhood experiences, as these are associated with hypertension development 1. This history may also suggest white coat hypertension if stress is identified 1.

Historical Features Distinguishing Primary from Secondary Hypertension

Primary hypertension is suggested by 1:

• Gradual BP increase with slow rate of rise
• Positive family history of hypertension
• Lifestyle factors favoring higher BP

Secondary hypertension is suggested by 1, 4:

• Age of onset <30 years or >55 years
• Abrupt onset or sudden worsening of previously controlled BP
• Severe hypertension (>180/120 mmHg) or resistant hypertension
• Absence of family history
• Target organ damage disproportionate to duration/severity

Common Pitfalls to Avoid

• Do not assume resistant hypertension without first confirming medication adherence and excluding interfering substances (NSAIDs, alcohol, recreational drugs) 2
• Recognize that intermittent symptoms like headaches and dizziness are nonspecific and do not constitute hypertensive emergency unless accompanied by acute target organ damage 5
• Remember that younger age at onset and negative family history should prompt more detailed investigation for secondary causes 2, 6