NURS 504 Week 4 Hypertension Case Study Analysis Example

Hypertension Case Study Analysis: Starting Two Drugs in One Pill for an Untreated Church Organist With Stage 2 Hypertension

Case Summary

The patient is a 52-year-old church organist and piano teacher referred after several elevated readings at a pharmacy kiosk. Office readings today, taken after five minutes of rest with a correctly sized cuff, average 152/96 mm Hg. A validated upper-arm home monitor used for a week, with a pair of readings taken every morning and every evening, gives an average of 148/94 mm Hg. The patient takes no medications, has a body mass index of 31, drinks two to three glasses of wine on weekends, walks little and eats many restaurant meals between lessons. Laboratory results show potassium of 4.1 mmol/L, an eGFR of 88, a urine albumin-to-creatinine ratio of 18 mg/g, an A1C of 5.9% and LDL cholesterol of 132 mg/dL. The electrocardiogram is normal.

Assessment

Both averages sit in the stage 2 range, which begins at 140 systolic or 90 diastolic (Jones et al., 2025). Confirming the diagnosis with home readings guards against white-coat effect, and the readings agree. There is no evidence of kidney damage, since the albumin ratio is below 30, and the electrocardiogram shows no left ventricular hypertrophy. The patient's ten-year cardiovascular risk, estimated with the PREVENT equations that the 2025 guideline adopted, is below the 7.5% threshold used for stage 1 decisions, but that threshold does not apply here: stage 2 hypertension warrants drug therapy along with lifestyle change regardless of calculated risk. Prediabetes and untreated LDL cholesterol add to long-term risk. The decision is not whether to start medication but how to reach goal quickly and keep the patient taking it.

Secondary Causes and Organ Review

Before treatment, the history and laboratory results should be reviewed for clues to a secondary cause. The patient has no low potassium, no episodes of headache with sweating and palpitations, no snoring with daytime sleepiness reported by a partner, and no use of decongestants, nonsteroidal anti-inflammatory drugs or other drugs that raise pressure. Kidney function and urine albumin are normal. The 2025 guideline broadened screening for primary aldosteronism, and if pressure proves hard to control or potassium falls on treatment, an aldosterone-to-renin ratio would be the next test. For now, primary hypertension is the most likely explanation.

Goal

The goal is a blood pressure below 130/80 mm Hg, the target the 2025 guideline keeps for most adults (Jones et al., 2025).

Pharmacologic Plan

Two Classes in One Pill

For stage 2 hypertension the 2025 guideline recommends starting with two first-line drugs from different classes, preferably as a single-pill combination, because most patients need at least two drugs and one pill improves adherence and shortens the time to control (Jones et al., 2025). The recommended choice is amlodipine-benazepril 5/20 mg once daily. The guideline no longer ties the choice of first-line drug to race, so the selection rests on the patient's other conditions and on outcome evidence.

Why This Combination

Benazepril, an ACE inhibitor, blocks the conversion of angiotensin I to angiotensin II, relaxing arterioles and reducing aldosterone release. Amlodipine, a dihydropyridine calcium channel blocker, relaxes vascular smooth muscle by blocking calcium entry (Burchum & Rosenthal, 2019). The two act on different mechanisms, and the ACE inhibitor offsets some of the ankle swelling amlodipine can cause. In the ACCOMPLISH trial of 11,506 high-risk patients with hypertension, benazepril combined with amlodipine reduced cardiovascular events more than benazepril combined with hydrochlorothiazide, with similar blood pressure lowering (Jamerson et al., 2008). That outcome evidence, and the absence of a metabolic effect on glucose in a patient with prediabetes, favor this pair over a thiazide combination as the first choice. If the patient were of childbearing potential, an ACE inhibitor would require reliable contraception, because the class is contraindicated in pregnancy.

Titration

If home readings remain above goal after four weeks, the dose can increase to 10/40 mg. If goal is still not reached, a thiazide-type diuretic such as chlorthalidone can be added as a third class (Wells et al., 2018).

Lipids

LDL cholesterol of 132 mg/dL with prediabetes and hypertension warrants a discussion of statin therapy based on the patient's overall risk, which can be revisited after blood pressure is controlled.

Lifestyle Measures

Lifestyle change adds to drug therapy and may allow fewer drugs later. The plan includes reducing sodium below 1,500 mg a day where possible, with an interim aim of cutting at least 1,000 mg from current intake; a diet rich in vegetables, fruit and low-fat dairy; a potassium-enriched salt substitute, since kidney function and potassium are normal; a weekly total of 150 or more minutes of moderate exercise, which for this patient could begin with a brisk walk after morning lessons; a 5% weight loss target; and keeping alcohol to a single drink on any day it is used (Jones et al., 2025).

Monitoring and Adverse Effects

Potassium and creatinine should be checked two weeks after starting the ACE inhibitor. Home readings should be reviewed at four weeks and monthly until goal is reached, then every three to six months. Amlodipine can cause ankle edema, flushing and headache. Benazepril can cause a dry cough, which may require switching to an angiotensin receptor blocker, and rarely angioedema, which is an emergency. Dizziness on standing should be reported, especially during the first weeks, and the patient should rise slowly from the organ bench after long rehearsals.

Adherence and Cost

A single daily pill is the most important adherence tool in the plan, and the generic combination is inexpensive at most pharmacies. Linking the dose to a fixed routine, such as setting the bottle beside the music the patient practices each morning, helps. The patient should bring the home monitor and the readings log to the four-week visit so the nurse can check the device against a clinic reading.

What the Four-Week Visit Should Look Like

If home readings at four weeks average, for example, 136/86 mm Hg with no side effects, the dose should increase to 10/40 mg rather than waiting for the next scheduled visit, because control within three months is the aim. If ankle swelling has appeared, the amlodipine dose can stay at 5 mg and a thiazide-type diuretic can be added instead. If a dry cough has started, benazepril should be replaced with an angiotensin receptor blocker in a combination pill with amlodipine. Each of these branches keeps the patient on two classes without returning to single-drug therapy.

Patient Education

The patient should continue home monitoring with the same technique: rest seated for five minutes before measuring, sit upright with support behind the back, keep the legs uncrossed and rest the arm on a table so the cuff sits level with the heart, no caffeine or exercise in the prior 30 minutes, two readings a minute apart. The patient should understand that hypertension rarely causes symptoms, so feeling well is not a reason to stop the pill, and should know which side effects require a call.

Teaching Points for Nursing Students

This case is useful for correcting three outdated habits. Students often expect one drug at a time, but stage 2 hypertension now starts with two. Many still learn race-based drug choices, which the current guideline has dropped. And blood pressure decisions are only as good as the measurement, so teaching home technique is as important as choosing the drug.

References

Burchum, J. R., & Rosenthal, L. D. (2019). Lehne's pharmacology for nursing care (10th ed.). Elsevier.

Jamerson, K., Weber, M. A., Bakris, G. L., Dahlöf, B., Pitt, B., Shi, V., Hester, A., Gupte, J., Gatlin, M., & Velazquez, E. J. (2008). Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients. The New England Journal of Medicine, 359(23), 2417-2428. https://doi.org/10.1056/NEJMoa0806182

Jones, D. W., Ferdinand, K. C., Taler, S. J., Johnson, H. M., Shimbo, D., Abdalla, M., Altieri, M. M., Bansal, N., Bello, N. A., Bress, A. P., Carter, J., Cohen, J. B., Collins, K. J., Commodore-Mensah, Y., Davis, L. L., Egan, B., Khan, S. S., Lloyd-Jones, D. M., Melnyk, B. M., . . . Williamson, J. D. (2025). 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM guideline for the prevention, detection, evaluation and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Hypertension, 82(10). https://doi.org/10.1161/HYP.0000000000000249

Wells, B. G., DiPiro, J. T., Schwinghammer, T. L., & DiPiro, C. V. (2018). Pharmacotherapy handbook (10th ed.). McGraw-Hill Education.