Station Title & Timing
- Title: Essential Hypertension and End-Organ Screening
- Total Duration: 10 minutes (2 minutes reading time, 8 minutes performance)
- Timing Warning: At 7 minutes (1 minute remaining)
Learning Objectives
- Physical Examination: Demonstrate a systematic screening for hypertensive end-organ damage (eyes, heart, peripheral vascular system).
- Clinical Reasoning: Interpret physical findings (specifically retinopathy) in the context of essential hypertension.
- Communication: Explain the implications of “silent” hypertension and the necessity of further monitoring using patient-centered language.
Patient Profile
- Name: Mr. Alex Dawson (or Ms. Alexa Dawson)
- Age: 25 years old
- Ethnicity: Caucasian
- Occupation: Graphic Designer
- Social History: Non-smoker, social alcohol only, sedentary lifestyle.
Presenting Complaint
- Presented to the GP for a follow-up after being deferred from a Red Cross blood donation due to a high blood pressure reading of 160/100 mmHg.
Contextual Information
- History of Presenting Complaint: Asymptomatic. No headaches, visual blurring, or chest pain.
- Past Medical History: Unremarkable. Secondary causes (renal artery stenosis, phaeochromocytoma) were ruled out in a previous visit via bloods/ultrasound.
- Medications: Nil. No OTC decongestants or NSAIDs.
- Family History: Father has hypertension and had a “heart event” at age 55.
Candidate Instructions
Setting: General Practice Clinic
Task:
- Perform a focused physical examination to screen for end-organ complications of hypertension.
- Briefly explain your findings to the patient and outline the immediate next step in management.
Note: You are not required to take a full history or screen for secondary causes, as these have already been addressed. Assume the examiner will provide findings upon request for specific maneuvers.
Standardised Patient (SP) Instructions
- Demeanour: Slightly anxious but cooperative. You are surprised because you “feel fine.”
- Key Question: “If I feel okay, why does it matter if the numbers are high?”
- Responses: If asked about symptoms (headache, etc.), say “No.” If asked about family history, confirm your father has high BP.
Examiner Checklist & Clinical Findings
The examiner will provide these findings only when the candidate correctly performs or describes the maneuver.
| System | Clinical Finding (To be provided to candidate) |
| Vital Signs | Pulse: 78 bpm, regular. BP: 160/100 mmHg. |
| Hands/Face | No xanthomas, no nicotine staining. No xanthelasma. |
| Fundoscopy | Positive finding: Arteriovenous (AV) nicking and copper wiring noted. No papilledema. |
| Neck | JVP is not visible (Normal < 3cm). No carotid bruits. |
| Precordium | Apex beat in 5th ICS, mid-clavicular line (not displaced). No heaves/thrills. |
| Auscultation | S1, S2 heard. No S3 or S4 gallop. Lungs are clear at both bases. |
| Abdomen | No hepatomegaly. No renal bruits. |
| Lower Limbs | No pitting edema. Peripheral pulses (DP/PT) are present but faint. |
Communication Triggers (Murtagh Approach)
- Open-ended: “How do you feel about these readings we’ve found today?”
- The “Why”: Explain that hypertension is the “silent killer” because damage happens internally without symptoms.
- Lay Language: Use “thickening of the vessels in the back of the eye” instead of “grade 2 hypertensive retinopathy.”
Assessment & Marking Guide
1. Preparation & Technique (WIPE):
- Washes hands, introduces self, confirms patient identity.
- Positions patient at 45 degrees and ensures adequate exposure.
2. Physical Examination (The H.E.A.R.T Screen):
- Eyes: Specifically requests fundoscopy (Critical Step).
- Heart: Palpates apex beat and auscultates for gallop rhythms/lung crepitations.
- Vascular: Checks JVP and peripheral pulses.
- Running Commentary: Uses “negative reporting” (e.g., “I am looking for swelling in the ankles which might suggest the heart is struggling; I see none.”)
3. Management & Communication:
- Correctly identifies the diagnosis: Essential Hypertension.
- Communicates the finding of retinopathy clearly.
- Proposes 24-hour Ambulatory Blood Pressure Monitoring (ABPM) as the gold standard next step.
Sample Performance: Model Response
Candidate: “Alex, I’ve finished the examination. While your heart sounds healthy and there is no fluid on your lungs, I did notice some changes in the small blood vessels at the back of your eyes, known as AV nicking. This tells us that the high blood pressure is already starting to affect your body.”
SP: “Is that permanent? What do we do now?”
Candidate: “It’s a sign we need to act. Before we start any life-long medication, I want to be 100% sure of your average numbers. I’d like to arrange a 24-hour wearable blood pressure monitor. This will take readings while you go about your day and sleep, giving us the most accurate picture. Does that sound like a reasonable plan?”