Anyone bored enough to help?

[Diablo2fan]

Well I frequent the forums alot as a quest, read multiple topics, and yall are a bunch of smart people
but anyways, Its my first semester in medical school at USUHS and one of my instructors approached me with this case study and told me to complete it by Monday and turn it in during class.
Its another case study, and its rediculous because we didn't even scratch the surface of any of the complexities covered in these "studies."
So I'll just tell you the questions, my anwsers, and we'll see how badly I fail

To begin with, my patient is African American, 47, and comes to the clinic with a concern for high blood pressure. During my initial exam, his BP in both arms = 156/94, and during my two follow up examinations his BP is still 150+/90+. During my physical assessment, everything is WDL - exception: vundi with vasoconstriction, s4 gallop, increased QRS voltage on ECG, high LDL low HDL, all other blood tests WDL.
What tests do you order, what do you do now, and would you make a Dx or DDx.

Skimming through my books and going through my epocrates software, I concluded the following:
Since the fundoscopy revealed vasoconstriction, I could assume it could be correlated to HTN and that the overall condition if left unchecked could lead to eye damage. The S4 gallop could indicate left ventricular ischemia, and the high voltage QRS could indicate LVH. In epocrates, it advises that high QRS voltage DDx=HTN AS AR coarctation MR.
As far as tests, would it be necessary to order : Glucose finger stick, stress test, another ECG, and CBC?
I would diagnose HTN, I don't think its too presumptious since during all 3 visits BP = abnormal, so as far as "what would you do now" is it safe to just provide education, indicate changes in lifestyle as far as diet and exercise?
this whole study isn't vital, its not graded, but I feel I should go the extra yard and ask for help thanks guys

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[Long Dong]

Well I frequent the forums alot as a quest, read multiple topics, and yall are a bunch of smart people
but anyways, Its my first semester in medical school at USUHS and one of my instructors approached me with this case study and told me to complete it by Monday and turn it in during class.
Its another case study, and its rediculous because we didn't even scratch the surface of any of the complexities covered in these "studies."
So I'll just tell you the questions, my anwsers, and we'll see how badly I fail

To begin with, my patient is African American, 47, and comes to the clinic with a concern for high blood pressure. During my initial exam, his BP in both arms = 156/94, and during my two follow up examinations his BP is still 150+/90+. During my physical assessment, everything is WDL - exception: vundi with vasoconstriction, s4 gallop, increased QRS voltage on ECG, high LDL low HDL, all other blood tests WDL.
What tests do you order, what do you do now, and would you make a Dx or DDx.

Skimming through my books and going through my epocrates software, I concluded the following:
Since the fundoscopy revealed vasoconstriction, I could assume it could be correlated to HTN and that the overall condition if left unchecked could lead to eye damage. The S4 gallop could indicate left ventricular ischemia, and the high voltage QRS could indicate LVH. In epocrates, it advises that high QRS voltage DDx=HTN AS AR coarctation MR.
As far as tests, would it be necessary to order : Glucose finger stick, stress test, another ECG, and CBC?
I would diagnose HTN, I don't think its too presumptious since during all 3 visits BP = abnormal, so as far as "what would you do now" is it safe to just provide education, indicate changes in lifestyle as far as diet and exercise?
this whole study isn't vital, its not graded, but I feel I should go the extra yard and ask for help thanks guys

I'm not a medicine resident but I'd start him on a thiazide or ace inhib and say the S4 is from diastalic dsyfunction. That's all I'd do an put in a medicine consult.

 

[Diablo2fan]

thanks dude-
Don't really understand why he wants me to apply knowledge that I haven't even learned, but I'll write down that I should prescribe thiazides and schedule a couple follow up exams afterwards

 

[TMP-SMX]

Half of the stuff you've said is way beyond my comprehension as I'm just halfway through second year, but you would definitely want a thiazide and a potassium sparing diuretic. The potassium sparing is to prevent excessive potassium loss due to the thiazide. You could try the ACEI, but there are potential side effects in African-Americans like cough and they may be less effective in certain patients. The ACEI wouldn't be as effective alone anyway.

 

[WellWornLad]

thanks dude-
Don't really understand why he wants me to apply knowledge that I haven't even learned, but I'll write down that I should prescribe thiazides and schedule a couple follow up exams afterwards

Maybe the point is in the learning, eh?

 

[meister]

I wouldn't even bother with an ACEI in an AA.

 

[Droopy Snoopy]

Eye is a good place to look for HTN-associated end organ damage. If he's got probs there, might want to check out other places that get dinged by HTN as part of your 'what now' workup.

 

[RisingSun]

I wouldn't even bother with an ACEI in an AA.

Good point. How is his blood glucose? All diabetics should be on an ACEI or an angiotension receptor blocker (ARB).

If not, start with dietary/lifestyle modifications (low salt diet, weight loss, etc.) before jumping to anti-HTN meds, unless Stage II (>160/100) - although he is pretty borderline.

But don't take my word for it (I'm frequently wrong). Do some digging around. You are a first year in your first semester. You are not supposed to know what drugs to prescribe, etc. Have fun with it.

 

[OncoCaP]

Well I frequent the forums alot as a quest, read multiple topics, and yall are a bunch of smart people
but anyways, Its my first semester in medical school at USUHS and one of my instructors approached me with this case study and told me to complete it by Monday and turn it in during class.
Its another case study, and its rediculous because we didn't even scratch the surface of any of the complexities covered in these "studies."
So I'll just tell you the questions, my anwsers, and we'll see how badly I fail

To begin with, my patient is African American, 47, and comes to the clinic with a concern for high blood pressure. During my initial exam, his BP in both arms = 156/94, and during my two follow up examinations his BP is still 150+/90+. During my physical assessment, everything is WDL - exception: vundi with vasoconstriction, s4 gallop, increased QRS voltage on ECG, high LDL low HDL, all other blood tests WDL.
What tests do you order, what do you do now, and would you make a Dx or DDx.

Skimming through my books and going through my epocrates software, I concluded the following:
Since the fundoscopy revealed vasoconstriction, I could assume it could be correlated to HTN and that the overall condition if left unchecked could lead to eye damage. The S4 gallop could indicate left ventricular ischemia, and the high voltage QRS could indicate LVH. In epocrates, it advises that high QRS voltage DDx=HTN AS AR coarctation MR.
As far as tests, would it be necessary to order : Glucose finger stick, stress test, another ECG, and CBC?
I would diagnose HTN, I don't think its too presumptious since during all 3 visits BP = abnormal, so as far as "what would you do now" is it safe to just provide education, indicate changes in lifestyle as far as diet and exercise?
this whole study isn't vital, its not graded, but I feel I should go the extra yard and ask for help thanks guys

Not sure if you all have accessmedicine in your intranet. You should look up hypertension treatment in a good resource like that.

(when you get there, click on the "treatment" sidebar link)

Pick this book from accessmedicine:
Hurst's The Heart >
Chapter 70. Diagnosis and Treatment of Hypertension
Arash Rashidi / Mahboob Rahman / Jackson T. Wright, Jr.

Just a brief intro as to what you'll find there:
First you'll want to stage him. He fits here: Stage 1 Hypertension, Systolic 140–159, Diastolic 90–99

You need a good history because goals for diabetics and patients with heart disease (and renal problems) have different goals than patients without those conditions. Thus, you'll want a good history to tease out all the risk factors (including family history of DM, HTN, renal failure, etc.)., smoking and all that. Don't just depend on lab tests to make your diagnosis. The history can make or break you.

<stepping on soap box>
Your instructor will most likely roll his or her eyes about this following point (and thus you may very well want to skip it), but when it comes to actually caring for a patient (as opposed to making your instructor happy with the answer he or she was looking for) this will be the biggest factor of compliance versus non-compliance (besides making sure that your meds are on the $4 generic list at Wal-Mart and/or that your patient can easily afford the co-pay of the med you prescribe. The most important history question for the male HTN patient (prior to prescribing anything) is a detailed sexual history, focusing on any issues of erectile dysfunction. Men, typically starting in their 40s, can start having problems in this department. Sadly, this is also when HTN shows up (and the two are related). Besides HTN, one of the big risk factors for this is diabetes. The reason you need to get this baseline history is that many of the medicines you'll be considering cause erectile dysfunction. So what you say, I'll just prescribe Viagra, right? You won't make it that far in many cases. In too many cases, your patient will stop taking the blood pressure medication and just not tell you about their little "problem" because you didn't establish a baseline and did not follow up on that to make sure there were no changes. Some care is required here because telling your patient that the med causes erectile dysfunction could lead to anxiety about this, and psychological factors are a common cause of erectile dysfunction. Failure to watch for the erectile dysfunction side effect could easily mean that the next time you'll see your patient is when they present with an MI, CV event (stroke), renal failure, or CHF. So, unless you like to waste your time prescribing meds your patients don't take (which is an unavoidable problem to some extent) you should try to remember this point.
</stepping off soap box>

Anyway, then there's the physical exam. Even though everything else is normal, it still bothers me that you don't have a heart rate or respiratory rate. For example, a heart rate of 88 might still be still considered "normal" but might motivate me to look into beta blockers a bit more. Anyway, here is the kind of information you'll find in this reference: "In addition to blood pressure measurement, the physical examination should search for signs of secondary hypertension and for evidence of organ damage. During the physical examination note should be made of blood pressure, features of Cushing syndrome, tuberous sclerosis or skin stigmata of neurofibromatosis (suggesting possible pheochromocytoma), palpation of enlarged kidneys (polycystic kidney), ..."

I guess if after you have looked at decent resources such as this, you may want to ask some follow up questions and get input from people who actually have managed patients like yours with hypertension to get that personal insight that you don't get from a reference (maybe ask in the residents and rotations forums). You should be able to get all this information online from your computer via your library's web site or medical school resource center online and elsewhere.

I'm sure after you look this over, the assignment won't seem as daunting. Part of the deal here is just getting used to working with this kind of information. You'll be learning for the rest of your life, and this case is good practice on something you'll need to know for the rest of your career, most likely. It really isn't unreasonable for your instructor to get you to think about these problems and looking at the different resources of information. You are not going to have studied every condition you will encounter in clinical practice. You'll need to look things up, especially in the beginning. Good luck and have fun with this. You will use what you learn with this ... I guarantee that.

Similarly for the S4 and other signs... you'll want to look those up and address them briefly in the context of HTN.

 

[smq123]

To begin with, my patient is African American, 47, and comes to the clinic with a concern for high blood pressure. During my initial exam, his BP in both arms = 156/94, and during my two follow up examinations his BP is still 150+/90+. During my physical assessment, everything is WDL - exception: vundi with vasoconstriction, s4 gallop, increased QRS voltage on ECG, high LDL low HDL, all other blood tests WDL.
What tests do you order, what do you do now, and would you make a Dx or DDx.

The S4 gallop could indicate left ventricular ischemia, and the high voltage QRS could indicate LVH. In epocrates, it advises that high QRS voltage DDx=HTN AS AR coarctation MR.

As far as tests, would it be necessary to order : Glucose finger stick, stress test, another ECG, and CBC?

so as far as "what would you do now" is it safe to just provide education, indicate changes in lifestyle as far as diet and exercise?

I hope that the S4 gallop doesn't indicate LV ischemia in this case, because that means that he had a heart attack some time ago. It probably means LVH in this case.

You don't really need a stress test at this point, unless he's complained of previous episodes of unexplainable chest pain. You don't need another ECG (what difference would it make?), and you don't really need a CBC either. A CBC isn't going to tell you much.

He probably needs a Chem 7 - check his BUN and creatinine and make sure his kidneys aren't shot. He should also have a fasting glucose test, although it doesn't really show you if he has insulin resistance or not. The Chem 7, if drawn first thing in the morning (before he eats) should also show that.

You don't need to start him on any meds for his HTN now - ACEI, thiazide diuretic, or otherwise. Diet and exercise are usually the first line treatments. If he smokes, he should stop, and if he's "fluffy" (as my internal med resident used to say), he should lose weight.

How high is his LDL? If it's high you could start him on lipitor or something.

If you want to be REALLY thorough, you could listen for a bruit from renal artery stenosis, although that's kind of unusual. Listen to his heart, and feel for the PMI.

 

[smq123]

The most important history question for the male HTN patient (prior to prescribing anything) is a detailed sexual history, focusing on any issues of erectile dysfunction.

The reason you need to get this baseline history is that many of the medicines you'll be considering cause erectile dysfunction.

Actually, I would argue that the most important history question for a male HTN patient is "Have you ever had any bouts of severe chest pain that you couldn't explain?"

Erectile dysfunction won't kill you, but an MI might.

Actually, the reason why you "might" need to know if the patient has erectile dysfunction is to see if he's already on Viagra. Viagra causes the blood vessels to dilate, and may lower your blood pressure. If you're on Viagra, and then add a medication that lowers blood pressure, then you might get hypotensive, which can sometimes be as dangerous.

As far as I am aware, the first line drugs generally prescribed for HTN (i.e. lasix and metoprolol) do NOT usually cause ED. HTN, by itself, can contribute to ED, but the medications usually do not.

Anyway, then there's the physical exam. Even though everything else is normal, it still bothers me that you don't have a heart rate or respiratory rate. For example, a heart rate of 88 might still be still considered "normal" but might motivate me to look into beta blockers a bit more

You don't really need a heart rate or a respiratory rate, to be honest. A respiratory rate of 12 vs. 16 doesn't tell you much (and when you do inpatient medicine, every patient seems to have a respiratory rate of 18, awake or asleep).

And a heart rate of 88 definitely doesn't merit a beta blocker.

 

[meister]

You don't really need a heart rate or a respiratory rate, to be honest. A respiratory rate of 12 vs. 16 doesn't tell you much (and when you do inpatient medicine, every patient seems to have a respiratory rate of 18, awake or asleep).

That's because the techs just make it up. I volunteered in a hospital and was actually told to do this by several nursing aids.

 

[smq123]

That's because the techs just make it up. I volunteered in a hospital and was actually told to do this by several nursing aids.

Yeah, my suspicions were confirmed when I saw a CNA standing in the hallway, randomly writing down O2 sats and respiratory rates for patients that she saw 45 minutes ago.

If a patient is sick enough that O2 sats and respirations matter, they're usually hooked up to electronic monitoring equipment (i.e. in the ICU).

 

[OncoCaP]

Actually, I would argue that the most important history question for a male HTN patient is "Have you ever had any bouts of severe chest pain that you couldn't explain?"

Erectile dysfunction won't kill you, but an MI might.

Actually, the reason why you "might" need to know if the patient has erectile dysfunction is to see if he's already on Viagra. Viagra causes the blood vessels to dilate, and may lower your blood pressure. If you're on Viagra, and then add a medication that lowers blood pressure, then you might get hypotensive, which can sometimes be as dangerous.

As far as I am aware, the first line drugs generally prescribed for HTN (i.e. lasix and metoprolol) do NOT usually cause ED. HTN, by itself, can contribute to ED, but the medications usually do not.



You don't really need a heart rate or a respiratory rate, to be honest. A respiratory rate of 12 vs. 16 doesn't tell you much (and when you do inpatient medicine, every patient seems to have a respiratory rate of 18, awake or asleep).

And a heart rate of 88 definitely doesn't merit a beta blocker.

I wasn't suggesting that you shouldn't ask about MI's. We should ask about PMH, FH, and any current symptoms of MI's. It's clearly something that must be asked in the history. No doubt about that. The reason I brought it up was because it is a common issue and cause of significant morbidity (and easy to remedy, ... we have great ED drugs). Asking about previous MI's is not something that is commonly forgotten.

Most HTN drugs, including the ones you listed, can cause ED:
http://www.webmd.com/erectile-dysfunction/guide/drugs-linked-erectile-dysfunction

It's almost impossible to predict if a given HTN med will work for a given patient. There are some correlations by race, etc., but it's a trial and error process at the end of the day. Recommendations are to start with a diuretic (plus others depending on the patient) but many physicians don't start with a diuretic.

The thing to keep in mind here is that the number of men on antihypertensives and diuretics is huge. Between "2005&#8211;2006, 29% of all U.S. adults 18 years and older were hypertensive (systolic BP &#8805; 140 mmHg or diastolic BP &#8805; 90 mmHg or taking medications for hypertension) (CDC data). ... Overall, 68% of adults with hypertension were using anti-hypertensive medication. ...The prevalence of hypertension was nearly equal between men and women." So if ~29% of men are hypertensive, ~68% are on hypertensive meds and we have 300 million Americans (and let's say half are men), then we have ~30 million men taking antihypertensives. Thus, even if a small percentage of men were non-compliant with the HTN med due to medication side effect (ED, etc.) the effect would be huge. I personally know of a handful of patients who required surgery or presented with CHF after they chose not to take their HTN meds due to ED, and I'm just starting my experience with patients.

Here is one article that illustrates the problem. Obviously I'm open to better stats & studies if anyone has some:

Evaluation of Erectile Dysfunction Therapy in Patients Previously Nonadherent to Long-Term Medications: A Retrospective Analysis of Prescription Claims.

Original Articles
American Journal of Therapeutics. 12(6):605-611, November/December 2005.
McLaughlin, Trent 1*; Harnett, James 2; Burhani, Soraya 1; Scott, Brian 1

Abstract:
Erectile dysfunction (ED) can lead to treatment noncompliance in patients taking medications for chronic health conditions. Using the Intelligent Health Repository, NDCHealth's longitudinal, United States health care claims database, we examined the impact of treating ED on adherence to long-term therapies in previously nonadherent patients. Male patients >=18 years of age were identified who received antidepressant (AD), antihypertensive (AH), oral hypoglycemic (OHG), or lipid-lowering (LL) agents and initiated therapy with sildenafil citrate (Viagra) between January and June 2003. Treatment adherence was determined using medication possession ratios (MPRs) for the 12 months before and after the first prescription of sildenafil. Prior to initiation of therapy for ED with sildenafil, 64% of patients with comorbid medications were not adherent (MPR <0.8). Among these patients, 728 (27%) received AD, 2112 (78%) received AH, 984 (18%) received OHG, and 1078 (40%) received LL agents, with 66% of patients receiving multiple therapeutic classes. During the 12-month period after the first sildenafil prescription, patients had a significant increase in medication adherence compared with the 12 months before the first prescription of sildenafil (P < 0.0001). The percentage of patients who became adherent (MPR >=0.8) with medications after sildenafil treatment was from 22% to 36%. With the exception of the LL group, there was a significant relationship between >=3 sildenafil prescriptions and change in MPR (P < 0.05). Patients aged >=65 years had similar improvement in MPR as patients <=65 years. Treatment of ED with sildenafil improved adherence in patients taking common long-term medications who were previously nonadherent.

(C) 2005 Lippincott Williams & Wilkins, Inc.

Based on this article (again, I'm open to better stats), ~29% of patients were non-adherent prior to ED meds. 29% of 30 million is about 9 million American men that might not be compliant with their HTN meds if it wasn't for ED meds. If if the number is 3% or .3%, we are still talking about a lot of mortality and morbidity.

I wouldn't fault you for not worrying about a heart rate of 88 because it isn't listed as one of the "official" CAD risk factors. However, there is some indication that it could be a risk factor for CAD and that makes sense to me. Also there is data to support the use of beta blockers in certain patients as well.:

European Heart Journal
Volume 26, Issue 10, May 2005, Pages 967-974

Long-term prognostic value of resting heart rate in patients with suspected or proven coronary artery disease

Diaz, A.a Show author details, Bourassa, M.G.a Show author details, Guertin, M.-C.b Show author details, Tardif, J.-C.a Show author detailsEmail this author Correspondence address

a Department of Medicine, Research Center, Montreal Heart Institute, 5000 Belanger Street E, Montreal, Que. H1T 1C8, Canada
b Montreal Heart Institute Coordinating Center (MHICC), Montreal, Que., Canada

Abstract

Aims: Heart rate reduction is the cornerstone of the treatment of angina. The purpose of this study was to explore the prognostic value of heart rate in patients with stable coronary artery disease (CAD). Methods and results: We assessed the relationship between resting heart rate at baseline and cardiovascular mortality/morbidity, while adjusting for risk factors. A total of 24 913 patients with suspected or proven CAD from the Coronary Artery Surgery Study registry were studied for a median follow-up of 14.7 years. All-cause and cardiovascular mortality and cardiovascular rehospitalizations were increased with increasing heart rate (P < 0.0001). Patients with resting heart rate &#8805;83 bpm at baseline had a significantly higher risk for total mortality [hazard ratio (HR) = 1.32, CI 1.19-1.47, P < 0.0001] and cardiovascular mortality (HR = 1.31, CI 1.15-1.48, P < 0.0001) after adjustment for multiple clinical variables when compared with the reference group. When comparing patients with heart rates between 77-82 and &#8805;83 bpm with patients with a heart rate &#8804;62 bpm, the HR values for time to first cardiovascular rehospitalization were 1.11 and 1.14, respectively (P < 0.001 for both). Conclusion: Resting heart rate is a simple measurement with prognostic implications. High resting heart rate is a predictor for total and cardiovascular mortality independent of other risk factors in patients with CAD. © The European Society of Cardiology 2005. All rights reserved.

Again, heart rate is less of an issue and I could see why it might not be a factor at 88 for many (or even most) clinicians) in what antihypertensive meds they chose.

 

[anon-y-mouse]

Umm, he HAS disease, i.e. long-standing hypertension -- his fundi are messed up, and he has an S4 gallop indicating LV stiffness, and increased QRS amplitude, indicating LVH (the other epocrates differentials you have can be ruled out just by the information you've provided). I don't think the appropriate initial treatment is diet + exercise, though that is definitely going to be part of it -- that would be more appropriate for anything pre-Stage I hypertension. This dude has Stage I, but he's teetering on Stage II, so we have to get his BP down by meds. In addition to the things people have recommended, I would do a fasting glucose test (and you'll need 2 to confirm DM), CBC (why not), CMP. I'm not sure what else the EKG said (there could be contraindications to stress tests!) or whether a stress test would be necessary- he doesn't have any chest pain. You might get an echo to look at the valves and check out his hemodynamics. And yes, you can diagnose hypertension in this case, it just takes two separate readings. I'd start him on HCTZ 25mg (always first line for African Americans unless they have diabetes), and/or depending on diabetic status, an ace inhibitor. Depending on his liver, I would definitely add a statin +/- niacin (raises HDL, lowers LDL). I would also consider Vytorin instead, which is a statin + ezetimibe, although the ezetimibe wouldn't really raise HDL so much as lowering LDL.

Yeah, and what the hell? The most important question to ask your hypertensive patient is about erectile dysfunction?!?! How about questions relating to signs and symptoms that will KILL the person?! This dude's a walking time-bomb for a stroke and/or heart failure w/ flash pulmonary edema, etc. etc. - I wouldn't be too concerned about ED right now.

 

[anon-y-mouse]

I wasn't suggesting that you shouldn't ask about MI's. We should ask about PMH, FH, and any current symptoms of MI's. It's clearly something that must be asked in the history. No doubt about that. The reason I brought it up was because it is a common issue and cause of significant morbidity (and easy to remedy, ... we have great ED drugs). Asking about previous MI's is not something that is commonly forgotten.

It's still NOT the most important history question as you said, although I agree that it is something to note down. I don't think anyone is arguing against your point that it is important, more your priorities in approaching this patient, so it's pretty much worthless to paste huge studies and journal articles that no one is going to read (please summarize and be more succinct! ), into the body of an SDN message.

 

[sprinkibrio]

Well I frequent the forums alot as a quest, read multiple topics, and yall are a bunch of smart people
but anyways, Its my first semester in medical school at USUHS and one of my instructors approached me with this case study and told me to complete it by Monday and turn it in during class.
Its another case study, and its rediculous because we didn't even scratch the surface of any of the complexities covered in these "studies."
So I'll just tell you the questions, my anwsers, and we'll see how badly I fail

To begin with, my patient is African American, 47, and comes to the clinic with a concern for high blood pressure. During my initial exam, his BP in both arms = 156/94, and during my two follow up examinations his BP is still 150+/90+. During my physical assessment, everything is WDL - exception: vundi with vasoconstriction, s4 gallop, increased QRS voltage on ECG, high LDL low HDL, all other blood tests WDL.
What tests do you order, what do you do now, and would you make a Dx or DDx.

Skimming through my books and going through my epocrates software, I concluded the following:
Since the fundoscopy revealed vasoconstriction, I could assume it could be correlated to HTN and that the overall condition if left unchecked could lead to eye damage. The S4 gallop could indicate left ventricular ischemia, and the high voltage QRS could indicate LVH. In epocrates, it advises that high QRS voltage DDx=HTN AS AR coarctation MR.
As far as tests, would it be necessary to order : Glucose finger stick, stress test, another ECG, and CBC?
I would diagnose HTN, I don't think its too presumptious since during all 3 visits BP = abnormal, so as far as "what would you do now" is it safe to just provide education, indicate changes in lifestyle as far as diet and exercise?
this whole study isn't vital, its not graded, but I feel I should go the extra yard and ask for help thanks guys

You are able to diagnose HTN after 2 visits with elevated BP. First I would stage the BP, it is stage I. Then I would treat with a thiazide diuretic and check blood pressure again in a few weeks to see if more medicine is needed. It looks like he already has end organ damage (an S4 means the ventricles are stiff--LV in this case because it's working hard against the increased BP, vasoconstriction on fundoscopic exam means the eyes are already affected, and there is LV hypertrophy on EKG, again because the heart is working very heard to pump), but it doesn't look like he has heart failure yet because there is no dyspnea or ascites.

He also has hypercholesterolemia. I would proscribe a statin to lower his LDL and raise his LDL and advise him to change his diet and exercise to remove a risk factor for atherosclerosis.

In terms of tests, I would do a stress test to check for possible ischemia due to the HTN and hypercholesterolemia (both risk factors for atherosclerosis, thus ischemia) and would test BUN and creatinine to check kidney function (kidneys are often affected in HTN).

 

[smq123]

I wasn't suggesting that you shouldn't ask about MI's. We should ask about PMH, FH, and any current symptoms of MI's. It's clearly something that must be asked in the history. No doubt about that.

You asid that your FIRST question would be about sexual dysfunction. Generally, you want your first question to ask about things that could potentially kill you - in this case, an MI and angina.

Asking first about sexual dysfunction is like seeing a pregnant woman who is in the throes of labor, and first asking her if she planned on breast feeding. Important? Sure. The MOST important thing? Not right now.

It's almost impossible to predict if a given HTN med will work for a given patient. There are some correlations by race, etc., but it's a trial and error process at the end of the day. Recommendations are to start with a diuretic (plus others depending on the patient) but many physicians don't start with a diuretic.

WHAT?! Yes they do. Many physicians definitely start with HCTZ or lasix first, adding a beta-blocker if they see fit. Lasix and HCTZ work for a lot of people, and there's no reason (besides possible allergies or electrolyte imbalances) not to try one.

Most HTN drugs, including the ones you listed, can cause ED.

I personally know of a handful of patients who required surgery or presented with CHF after they chose not to take their HTN meds due to ED, and I'm just starting my experience with patients.

I wouldn't fault you for not worrying about a heart rate of 88 because it isn't listed as one of the "official" CAD risk factors. However, there is some indication that it could be a risk factor for CAD and that makes sense to me.

- The website given just lists HTN meds that may, or may not, cause ED. What it does NOT list is the percentage of patients who reported such a side effect. For Lopressor, it was ~2%, and for Lasix it was 1%. I'm not going to worry if the patient in the case study falls into that 1-2%.

- People rarely develop CHF overnight. We're just talking about starting a man on some hypertension treatment. I'm still not going to make ED a priority at this point.

- Well, sure you want to reduce stress on the heart in any patient with CAD. Beta-blockers are not a bad idea in someone with a risk of MI.

You're spending way too much time here chasing zebras, especially for an initial few visits. The man clearly has HTN. I'm not going to waste a lot of time worrying about potential ED (unless there will be a medication interaction), and I'm not going to waste time worrying about his totally normal heart rate. Later, maybe. But not now.

In addition to the things people have recommended, I would do a fasting glucose test (and you'll need 2 to confirm DM), CBC (why not), CMP.

You're probably right - starting treatment right now is probably not a bad idea.

I still wouldn't get a CBC though. I suggested that on family med (having just gotten off internal med, where you always get a CBC on EVERYONE), and the preceptor just gave me this look:

And then he asked me to justify that answer. Uhhh....

I learned my lesson after that one.

I guess a CMP would be better than a BMP if you're checking to see if you can start a statin. Either one at this juncture, depending on how "high" his LDL is.

 

[OncoCaP]

It's still NOT the most important history question as you said, although I agree that it is something to note down. I don't think anyone is arguing against your point that it is important, more your priorities in approaching this patient, so it's pretty much worthless to paste huge studies and journal articles that no one is going to read (please summarize and be more succinct! ), into the body of an SDN message.

While the sentence in question by itself is incorrect, my point was clearly in a paragraph on patient medication compliance, and it is a very important question in that context. I should have been more careful to again remind the reader of the context in case he or she forgot what the previous sentence and the rest of the paragraph is talking about. I'll recalibrate. Back to the issue: if you patient doesn't take the meds, they aren't going to see a therapeutic effect and you have pretty much just wasted your time and your patient's time. The point can't be overemphasized. It's not just something to "note down." That's actually what I'm getting at. There are probably countless patients on 3 or 4 blood pressure meds that "aren't working" because the patient isn't taking them and the physician just assumes it's an issue with the drug for that patient and tries something else. Finally the physician gives up and assumes the patient's BP can't be controlled sufficiently with these meds. Naturally this issue isn't limited to this particular class of meds and this particular side effect. There are of course other ailments treated with classes of meds that have common side effects that could affect compliance. If there is something that will improve the health of 9 million Americans, it's worth paying attention to.

When I speak with physicians or residents they often mention how they hate it when patients are non-compliant. It's one of the most common (e.g., #1) complaints I hear. My point above addresses this "quality of life" issue for physicians and the effectiveness of treatment for the patient. I'm not suggesting that getting an accurate diagnosis or PMH is somehow secondary. When you time how long the physician spends discussing the treatment drug versus everything else it's often a very small percentage of the time spent with the patient because it's too easy to assume that the patient will do the right thing. Prescribing expensive medications for a patient will little or no discretionary income is another all too common occurrence. Then these folks go to the pharmacy and choose which medications they are going to take that month, often on the basis of the out-of-pocket cost. There are patients on 5 meds who will just get the cheapest med filled. Prescribing the patient here a med with a $50 copay could be a showstopper in terms of effective treatment because they patient isn't going to get that filled. These are all basic issues that are easy to miss and often easy to prevent.

I'll cut back on the study cut & pastes. Sorry about that.

 

[smq123]

In terms of tests, I would do a stress test to check for possible ischemia due to the HTN and hypercholesterolemia (both risk factors for atherosclerosis, thus ischemia)

Why get a stress test?

You usually reserve stress tests for patients who have shown symptoms of chest pain, dyspnea with exertion, angina, etc. If he's ever had a questionable MI in the past that he didn't do anything about (i.e. it hurt but he decided to "wait it out,") then, sure. Until then, those tests are expensive for the patient, and hard to justify to health insurances unless you have some really good indication for doing it.

 

[OncoCaP]

You asid that your FIRST question would be about sexual dysfunction. Generally, you want your first question to ask about things that could potentially kill you - in this case, an MI and angina.

Asking first about sexual dysfunction is like seeing a pregnant woman who is in the throes of labor, and first asking her if she planned on breast feeding. Important? Sure. The MOST important thing? Not right now.

I never said it was the first question I would ask the patient. You're chasing figments of your imagination. Come visit reality and it will become more clear. You continue to drum up disagreements just for the point of argument. You want there to be an issue where there is none.

WHAT?! Yes they do. Many physicians definitely start with HCTZ or lasix first, adding a beta-blocker if they see fit. Lasix and HCTZ work for a lot of people, and there's no reason (besides possible allergies or electrolyte imbalances) not to try one.

I really hate to point out the obvious again, but it is entirely possible that "many" physicians start with HCTZ or lasix and that "many" don't. "Many" is pretty vague. Take a look at this article: http://www.ncbi.nlm.nih.gov/pubmed/12448641 . Starting with something other than a diuretic for HTN is a common practice.

- The website given just lists HTN meds that may, or may not, cause ED. What it does NOT list is the percentage of patients who reported such a side effect. For Lopressor, it was ~2%, and for Lasix it was 1%. I'm not going to worry if the patient in the case study falls into that 1-2%.

The percentage varies. I cut and pasted a study above that said estimated it was ~29% experience such side effects. I think the numbers you give above are low, but I'm certainly interested in getting accurate numbers, whatever they might be. It's a significant issue from what I have observed with my own two eyes and ears. I'm less sure about the national stats, and that's why I pulled the above references. I'm interested large-scale studies for this class of medications (more of an aggregate) with respect to HTN medication compliance for a variety of factors (from cost to side effects, etc.). I'm not sure who would fund them; drug companies certainly don't want to make an issue of this.

- People rarely develop CHF overnight. We're just talking about starting a man on some hypertension treatment. I'm still not going to make ED a priority at this point.

Sure, and smoking doesn't cause lung cancer overnight either. That doesn't mean there isn't a very strong association there. Untreated HTN has all kinds of morbidity and mortality. Again, you missed the obvious ... that I pointed out the original poster that my point was more for his/her own information than as an answer to the case. Reading. Do it.

- Well, sure you want to reduce stress on the heart in any patient with CAD. Beta-blockers are not a bad idea in someone with a risk of MI.

Agreed.

You're spending way too much time here chasing zebras, especially for an initial few visits. The man clearly has HTN. I'm not going to waste a lot of time worrying about potential ED (unless there will be a medication interaction), and I'm not going to waste time worrying about his totally normal heart rate. Later, maybe. But not now.

If an issue that affects potentially 9 million Americans is a "zebra," then sign me up for the safari.

 

[TMP-SMX]

Avoid a beta blocker first, especially for African Americans as that is a drug class has more side effects and are less effective than diuretics by far as a monotherapy. Try the two diuretics first. You should also check for asthma as that is a definite no-no for beta blockers.

 

[sprinkibrio]

Why get a stress test?

You usually reserve stress tests for patients who have shown symptoms of chest pain, dyspnea with exertion, angina, etc. If he's ever had a questionable MI in the past that he didn't do anything about (i.e. it hurt but he decided to "wait it out,") then, sure. Until then, those tests are expensive for the patient, and hard to justify to health insurances unless you have some really good indication for doing it.

Cool, thanks for the correction. My only justification was in my previous post, but yeah, it's not good.

 

[smq123]

The most important history question for the male HTN patient (prior to prescribing anything) is a detailed sexual history, focusing on any issues of erectile dysfunction.

I never said it was the first question I would ask the patient. You're chasing figments of your imagination.

But you DID say that it was the "most important history question." If it's the "most important history question," don't you generally ask it FIRST?

Hey, you were wrong. Stop backpedaling. It's okay to be wrong - it's expected to be wrong! You're an MS2, after all. Why are you insist on defending something that is, in all honesty, not correct?

Starting with something other than a diuretic for HTN is a common practice.

Come back and talk after you've done your family med outpatient rotation.

Physicians start with a diuretic and/or beta-blocker for the vast majority of patients. Because of side effects, you often wait on the ARBs and the ACEIs until later.

Have you heard of the JNC VII? Here is how they break down HTN and the therapies for each stage of HTN....and most physicians follow these recommendations.

Initial therapy based on the JNC VII report recommendations is as follows:

• Prehypertension (systolic 120-139, diastolic 80-89): No antihypertensive drug is indicated.
• Stage 1 hypertension (systolic 140-159, diastolic 90-99): Thiazide-type diuretics are recommended for most. ACE inhibitor, angiotensin II receptor blocker (ARB), beta-blocker, calcium channel blocker, or combination may be considered.
• Stage 2 hypertension (systolic more than 160, diastolic more than 100): Two-drug combination (usually thiazide-type diuretic and ACE inhibitor or ARB or beta-blocker or calcium channel blocker) is recommended for most.
• For the compelling indications, other antihypertensive drugs (eg, diuretics, ACE inhibitor, ARB, beta-blocker, calcium channel blocker) may be considered as needed.

eMedicine is a wonderful resource, I have to say.

Sure, and smoking doesn't cause lung cancer overnight either. That doesn't mean there isn't a very strong association there. Untreated HTN has all kinds of morbidity and mortality. Again, you missed the obvious ... that I pointed out the original poster that my point was more for his/her own information than as an answer to the case. Reading. Do it.

<sigh>

Your patronizing tone, and command of "Reading. Do it." is highly unwelcome and unnecessary. Particularly when you're the one who made a recommendation (going so far as to step on a virtual soapbox), that has turned out not to be the best plan or management step right now.

You are falling into the same trap that I did while doing my rotations. There are things that need to get done NOW....and things you will do later. One of the most common questions that the attending asks the student or the resident is, "So what are we going to do TODAY." If a 52 year old lady comes in with bad arthritis, do you necessarily waste time telling her about the importance of getting a colonoscopy? No, although she needs one at some point in the future. What you're going to do TODAY, though, is take care of her arthritis.

What needs to be done TODAY is to address the patient's Stage 1 HTN - how to begin treating it, and to stave off any immediate life-threatening conditions. What needs to be done at a follow-up visit is to talk to the patient about how the medications are working, whether the patient has had trouble keeping track of the medications, whether the patient has suffered any side effects, etc.

No one said that medication compliance isn't important. Of course it is. Is it the most important thing RIGHT NOW? No.

 

[OncoCaP]

Umm, he HAS disease, i.e. long-standing hypertension -- his fundi are messed up, and he has an S4 gallop indicating LV stiffness, and increased QRS amplitude, indicating LVH (the other epocrates differentials you have can be ruled out just by the information you've provided). I don't think the appropriate initial treatment is diet + exercise, though that is definitely going to be part of it -- that would be more appropriate for anything pre-Stage I hypertension. This dude has Stage I, but he's teetering on Stage II, so we have to get his BP down by meds. In addition to the things people have recommended, I would do a fasting glucose test (and you'll need 2 to confirm DM), CBC (why not), CMP. I'm not sure what else the EKG said (there could be contraindications to stress tests!) or whether a stress test would be necessary- he doesn't have any chest pain. You might get an echo to look at the valves and check out his hemodynamics. And yes, you can diagnose hypertension in this case, it just takes two separate readings. I'd start him on HCTZ 25mg (always first line for African Americans unless they have diabetes), and/or depending on diabetic status, an ace inhibitor. Depending on his liver, I would definitely add a statin +/- niacin (raises HDL, lowers LDL). I would also consider Vytorin instead, which is a statin + ezetimibe, although the ezetimibe wouldn't really raise HDL so much as lowering LDL.

Your instructor may want you to hold off on the treatment recommendations until you have a diagnosis (i.e., you have your labs back) and ruled out other possibilities in your differential diagnosis.

Just to review the Hx & PE, since several people don't seem to remember what that entails:

"History and Physical Examination and Laboratory Evaluation

"The three main goals of the initial evaluation of the hypertensive patient are to (1) assess the presence of target-organ damage related to hypertension, especially those that might influence choice of therapy, (2) determine the presence of other cardiovascular risk factors and disease, and (3) evaluate for possible underlying secondary causes of hypertension. These goals are usually accomplished by a thorough medical history, physical examination, and simple laboratory investigations.8

"History

The key issues that need to be addressed in the history include:

* Duration, age of onset, and previous levels of high blood pressure;
* Previous antihypertensive therapy, its impact on blood pressure and adverse effects;
* Symptoms suggestive of secondary causes of hypertension (see Secondary Causes of Hypertension below);
* Lifestyle factors, such as dietary intake of fat, salt, alcohol, smoking, and physical activity, weight gain since early adult life;
* History of symptoms of neurologic dysfunction, heart failure, coronary heart disease, or peripheral arterial target-organ damage;
* Use of medications that influence blood pressure such as oral contraceptives, licorice, carbenoxolone, nasal drops, cocaine, amphetamines, steroids, nonsteroidal anti-inflammatory drugs, erythropoietin, and cyclosporine; and
* Presence of other cardiovascular risk factors.13

"Laboratory Tests

"Routine investigations before initiation of therapy include urine for protein and blood; serum creatinine (estimated glomerular filtration rate [GFR]) and electrolytes; fasting blood glucose; fasting lipid profile; and electrocardiogram (ECG). Generally, it is not necessary to do more extensive tests unless blood pressure control is not achieved or there are clinical or laboratory clues of secondary hypertension. An echocardiogram may be helpful in evaluating cardiac function in patients with cardiac symptoms or findings. Additional workup is guided by the clinical presentation in an individual patient, and the need to evaluate possible causes of secondary hypertension.

Source: Hurst's The Heart >
Chapter 70. Diagnosis and Treatment of Hypertension
Arash Rashidi / Mahboob Rahman / Jackson T. Wright, Jr.
(c) 2008

 

[anon-y-mouse]

While the sentence in question by itself is incorrect, my point was clearly in a paragraph on patient medication compliance, and it is a very important question in that context. I should have been more careful to again remind the reader of the context in case he or she forgot what the previous sentence and the rest of the paragraph is talking about. I'll recalibrate. Back to the issue: if you patient doesn't take the meds, they aren't going to see a therapeutic effect and you have pretty much just wasted your time and your patient's time. The point can't be overemphasized. It's not just something to "note down." That's actually what I'm getting at. There are probably countless patients on 3 or 4 blood pressure meds that "aren't working" because the patient isn't taking them and the physician just assumes it's an issue with the drug for that patient and tries something else. Finally the physician gives up and assumes the patient's BP can't be controlled sufficiently with these meds. Naturally this issue isn't limited to this particular class of meds and this particular side effect. There are of course other ailments treated with classes of meds that have common side effects that could affect compliance. If there is something that will improve the health of 9 million Americans, it's worth paying attention to.

When I speak with physicians or residents they often mention how they hate it when patients are non-compliant. It's one of the most common (e.g., #1) complaints I hear. My point above addresses this "quality of life" issue for physicians and the effectiveness of treatment for the patient. I'm not suggesting that getting an accurate diagnosis or PMH is somehow secondary. When you time how long the physician spends discussing the treatment drug versus everything else it's often a very small percentage of the time spent with the patient because it's too easy to assume that the patient will do the right thing. Prescribing expensive medications for a patient will little or no discretionary income is another all too common occurrence. Then these folks go to the pharmacy and choose which medications they are going to take that month, often on the basis of the out-of-pocket cost. There are patients on 5 meds who will just get the cheapest med filled. Prescribing the patient here a med with a $50 copay could be a showstopper in terms of effective treatment because they patient isn't going to get that filled. These are all basic issues that are easy to miss and often easy to prevent.

I'll cut back on the study cut & pastes. Sorry about that.

Dude. Have you ever even talked to a patient? First of all, this is an initial visit, so while I might still ask about ED, this guy isn't taking any medications for him to be compliant or non-compliant with yet. If you level with your patient and gain their trust, you will be able to ask them openly and honestly about why they aren't taking their medication. It happens. The key is to be non-judgmental, open, and accepting -- and they'll let you know exactly what the problem is, and you can go from there. Furthermore, if you assume we're all idiots and are going to prescribe the most expensive medication with the worst side effects at the first visit, then I feel really disrespected. Also, you'd be a pretty bad doctor if your patients didn't take the medications you prescribed and were afraid to tell you. It's going to happen to all of us, but earning that trust is the key to compliance. But, to your credit, the answer to the USMLE/shelf question which asks the most likely explanation of a patient who has failed n combinations of x medications for some condition is noncompliance, not something like renovascular stenosis, etc. Nevertheless, you can't go ahead and assume at the outset that they aren't going to be compliant with your medication. Also, as a side note, with your "I'd be tempted to try beta blockers with that heart rate" comment -- lopressor kind of sucks in terms of side-effects, from personal experience. I'd rather pee a lot than feel loopy.

Do you have that much of an ego that you can't say "sorry, ED isn't the MOST important thing to ask about with someone with hypertension"? Instead you're just hiding behind a whole bunch of non-sequiturs and logorrhea, and passive "while the sentence itself is not correct" without taking any responsibility. We get your point, ask about ED at some point. But I don't agree that it's the most important thing.

I don't know if you've had your internal medicine rotation yet, but you WILL fall on your face if you don't answer "HCTZ" for first line antihypertensive for African American without diabetes. That is the standard of care and has been shown by many important studies. I have no idea where you got "many" physicians from (and I hope you don't turn around and show me some crapass study in the south-east arkansas journal of podunk medicine), but if they aren't doing HCTZ for AA's and ACEi's for diabetics and others, they are practicing substandard medicine. Yes, that includes the random pubmed listing you cited for some place in Central Georgia. You don't advance your point at all when you cite underpowered, out of date studies.

Also, my treatment recommendations are correct. You can diagnose hypertension already. Apart from listening to frank bruits (I've never heard one, has anyone?), I'm not going to waste my time asking about carbenoxolone, cyclosporine, licorice, etc. If they're on cyclosporine, OCP's, etc. etc. the PMH and medications list should have it, and I know I would definitely clue in to that. This is a cut and dry PBL case and without any complications, my cut and dry workup and treatment recommendation is standard of care.

 

[BigSky]

I don't understand a GD thing you guys are talking about in here.

How long into medical school does one have to be before these sorts of things have any meaning?

 

[Diablo2fan]

I appreciate the responses guys, I'll nix the stresstest, ecg, and cbc
I'll look into adding a fasting glucose and kidney tests as well, and during education I'll add in ED. I guess I forgot to mention that his PMI is at 5th ICS, so that's normal. I was reading about heart sounds and yea you guys are right, an S4 isn't really indicative of anything serious but just gives a sign of "Decreased ventricular compliance" (stiffening as you guys said). It does mention that if the gallop was heard on S3 it would be indicative of left sided heart failure, so I'll see how long I can remember that. I would Dx stage 1 htn, provide education, and prescribe, as well as listen to bruits (should I listen to all the lower-abd bruis like aorta, illiac, renal, femoral ect?). Thank you all, really appreciate everyones insight, now I needa study for my biochem- If you anyone has questions relating to biochem I might be able to help​

 

[smq123]

How long into medical school does one have to be before these sorts of things have any meaning?

Definitely by the end of your 2nd year.

I would Dx stage 1 htn, provide education, and prescribe, as well as listen to bruits (should I listen to all the lower-abd bruis like aorta, illiac, renal, femoral ect?).

No need to listen to all of those bruits.

The main reason why we're talking about listening for bruits is to try and see if the patient has renal artery stenosis. Narrowing of the renal artery can be a cause of HTN, which wouldn't necessarily go away with meds.

Good luck with biochem!

 

[sprinkibrio]

I don't understand a GD thing you guys are talking about in here.

How long into medical school does one have to be before these sorts of things have any meaning?

Post cardio MS2.

 

[BigSky]

Post cardio MS2.

Amazing the difference two years can make eh?

 

[OncoCaP]

Dude. ..

Also, my treatment recommendations are correct. You can diagnose hypertension already. Apart from listening to frank bruits (I've never heard one, has anyone?), I'm not going to waste my time asking about carbenoxolone, cyclosporine, licorice, etc. If they're on cyclosporine, OCP's, etc. etc. the PMH and medications list should have it, and I know I would definitely clue in to that. This is a cut and dry PBL case and without any complications, my cut and dry workup and treatment recommendation is standard of care.

Dude, this isn't a clinical rotation question ("Its my first semester in medical school at USUHS") and so you can put away your Internal Medicine certificates of achievement. The person asking the question isn't on his internal medicine clerkship or Internal medicine residency or Cardiology fellowship, and so you can also put away your knee-jerk diagnosis and treatment plan and think back to the old days before your STEP1 and clinical rotations ... way back, when they made you write out the abbreviations and DDx's. Think back to PMI is at 5th ICS .. normal or not? They don't know much about treatment plans at this point yet and coming back with more than a one liner for the meds is probably missing something that they have learned about.

If the answer isn't in the course notes, then it will almost certainly be in standard references. It's basically textbook time. If it's not in the prof's notes or it's not in a textbook, it's probably not the right answer unless you were instructed to use some kind of special resource (ask a cardiologist, etc.). What worries me about the OP's reply is that s/he's made a diagnosis and is doing a physical exam step as a concluding statement of the case. If you've made your diagnosis, parts of physical exam aren't going to be the next step. The physical exam comes before the diagnosis; we're talking basics here.

Some thought needs to be given to what this prof is looking for. If they have been studying the importance of making a differential diagnosis and not jumping to conclusions, then SURPRISE the answer is you need to make a DDx and eliminate the possibilities before you prescribe every hypertensive you can remember. If they just learned that they should use different treatment regimens for essential HTN versus HTN+DM or HTN+DM+CAD+FH, then something needs to be said about that. +/- niacin is nowhere in this equation and nor is ezetimibe. We don't have the blood glucose back yet, so that might need to be considered before recommending treatment and a goal.

How do I know this? Because I've seen this kind of thing ... you'll talk to a cardiologist about case and come back and see your Internal Medicine attending who says ... not so fast. Let's a get a diagnosis (which to this attending meant getting all the labs back, working through the DDx, etc. Any medical treatment before then would be a bad thing.) You basically need to find out what your prof wants (both the written and unwritten instructions) and give them that. If they just had a lecture on formulating a DDx and working through it and you come back with a Dx, you get no points.

If the prof didn't give an indication one way or the other, then I'd put a DDx just to be safe and maybe suggest an initial treatment and wait for the blood glucose test results to come back because it makes a difference whether the guy is a diabetic as to what our goal and initial meds should be. As long as you back it up with reputable published sources, you will get some credit.

Also, your treatment recommendations are only correct if the has pt essential HTN and if that's the answer the prof is looking for. The person grading the assignment makes the rules. If the patient has a pheo or renal artery stenosis, you are heading down the wrong path and just got the treatment completely wrong. Yes, I know about odds and being able to take corrective actions if the patient doesn't improve, but it all depends on what this student's prof is looking for and giving that.

 

[smq123]

so you can also put away your knee-jerk diagnosis and treatment plan

Actually, the OP's assignment DID ask for diagnosis and treatment plan.

What tests do you order, what do you do now

What worries me about the OP's reply is that s/he's made a diagnosis and is doing a physical exam step as a concluding statement of the case. If you've made your diagnosis, parts of physical exam aren't going to be the next step. The physical exam comes before the diagnosis; we're talking basics here.

If we're talking basics here, then the OP CAN make a diagnosis of HTN, based on multiple BP readings that are higher than normal.

True, when you get to third/fourth year, then you have to go farther into primary vs. secondary, etc. But, like you said, basics.

Also, your treatment recommendations are only correct if the has pt essential HTN and if that's the answer the prof is looking for. The person grading the assignment makes the rules. If the patient has a pheo or renal artery stenosis, you are heading down the wrong path and just got the treatment completely wrong.

Aren't you the one who was talking about "basics"?

Who the heck covered pheochromocytomas and renal artery stenosis in their first year?

 

[Captain Fantastic]

FWIW, I go to a PBL school and, as a first year, if we were to outright diagnose the patient with HTN and not consider alternative hypotheses we would fail. Here the emphasis is on critical thinking and demonstrating how you came to your diagnosis (what else you considered, how your ranked them for likelihood, and what diagnostic studies do you need to test your hypotheses).

Like I said, FWIW. If your instructor is looking for you to recognize this as the definition of a Pt w/ HTN and wants you to know the JNC 7 guidelines, then a beautiful DDx won't get you very far.

 

[scotties123]

we were told that whenever we have an african american patient, we should test for anemia.

 

[TMP-SMX]

we were told that whenever we have an african american patient, we should test for anemia.

Male? Any abdominal pain?

I just wanted to add that beta blockers are also a nono for diabetics as they can reduce the symptoms of hypoglycemia.

 

[LadyWolverine]

Omg, this thread makes me want to throw up. For f*c&'s sake, the patient has stage 1 HTN and is showing signs of LVH (high volt QRS, S4 from stiff ventricle) and end-organ damage (fundoscopic exam). He's also dyslipidemic (high LDL, low HDL).

He needs to quit smoking if he does, follow a healthier diet/exercise plan, and who in the name of God said that we usually DON'T start people on HCTZ first?? Check his kidney function with a CMP since he already has signs of end-organ damage in his fundo exam. Check glucose - if he has DM and proteinuria, give him an ACE-I. Maybe check an echo to see the extent of heart dysfunction. Stress test won't tell you anything; he's not presenting with angina. I guess you could see if he has complaints/signs related to malignant HTN (headache, changes in mental status, papilledema on exam, blurry vision), but I think it's pretty straightforward that his BP is hovering around 160/90. It's most likely primary (essential) HTN.

I agree that it's an important exercise for medical students to consider the entire ddx which includes all the causes of secondary HTN (renal artery stenosis, pheo, renal insufficiency, Cushing's, etc), but just remember that the overwhelming majority of HTN that you are going to see is primary HTN. ESPECIALLY if it's someone coming in to an outpatient clinic because he has been told that he has high blood pressure. I think it's worth it just to know primary HTN in and out, especially how to manage/JNC VII.

I am 6 months into my 3rd year and I have already seen more cases of essential HTN than I can count. I've seen several cases of malignant HTN caused by people who didn't take their meds/binged on salt/didn't go to dialysis and ended up in the ED with a splitting headache and mental status changes - these patients have all been pretty sick and would not simply present to an outpatient clinic with "cc: hypertension." I have yet to see a case of RAS or pheo, only plenty of negative renal dopplers.

I think it's a valuable lesson to learn horses vs zebras, even as a first-year.

 

[Jwax]

No need to listen to all of those bruits.

The main reason why we're talking about listening for bruits is to try and see if the patient has renal artery stenosis. Narrowing of the renal artery can be a cause of HTN, which wouldn't necessarily go away with meds.

I think we ought to at the least check for carotid bruits. He has HTN and an elevated lipid panel, which would give him increased risk for carotid stenosis, no? Besides, it takes all of 15 seconds to do so what does it hurt?

Post cardio MS2.

Yep. I recall seeing posts like this on here only a short time ago and not understanding any of it. Cardio /resp was our 2nd test block of M2 (finished a few weeks ago) so now all of this stuff makes sense, even though I can't keep straight what extra heart sound indicates what issue. No matter, I highly doubt I could hear it yet anyways.

 

[OncoCaP]

Omg, this thread makes me want to throw up. For f*c&'s sake, the patient has stage 1 HTN and is showing signs of LVH (high volt QRS, S4 from stiff ventricle) and end-organ damage (fundoscopic exam). He's also dyslipidemic (high LDL, low HDL).

He needs to quit smoking if he does, follow a healthier diet/exercise plan, and who in the name of God said that we usually DON'T start people on HCTZ first?? Check his kidney function with a CMP since he already has signs of end-organ damage in his fundo exam. Check glucose - if he has DM and proteinuria, give him an ACE-I. Maybe check an echo to see the extent of heart dysfunction. Stress test won't tell you anything; he's not presenting with angina. I guess you could see if he has complaints/signs related to malignant HTN (headache, changes in mental status, papilledema on exam, blurry vision), but I think it's pretty straightforward that his BP is hovering around 160/90. It's most likely primary (essential) HTN.

I agree that it's an important exercise for medical students to consider the entire ddx which includes all the causes of secondary HTN (renal artery stenosis, pheo, renal insufficiency, Cushing's, etc), but just remember that the overwhelming majority of HTN that you are going to see is primary HTN. ESPECIALLY if it's someone coming in to an outpatient clinic because he has been told that he has high blood pressure. I think it's worth it just to know primary HTN in and out, especially how to manage/JNC VII.

I am 6 months into my 3rd year and I have already seen more cases of essential HTN than I can count. I've seen several cases of malignant HTN caused by people who didn't take their meds/binged on salt/didn't go to dialysis and ended up in the ED with a splitting headache and mental status changes - these patients have all been pretty sick and would not simply present to an outpatient clinic with "cc: hypertension." I have yet to see a case of RAS or pheo, only plenty of negative renal dopplers.

I think it's a valuable lesson to learn horses vs zebras, even as a first-year.

I'm sure you are good at what you do and get your diagnosis right a large percentage of the time. The main reply I have is that if you misdiagnose the patient's ailment and no one ever finds out at your school/hospital (and you diagnosed something reasonable based on the symptoms, etc.) you get to continue on your merry way. That 1 in 1000 person that you might potentially misdiagnose by playing odds might not live so happily ever after. I truly appreciate the joy of a diagnosis that is right 99.99% of the time. However, if there is something fairly easy and inexpensive that we can do (*and* have the time and money to do) to bring that diagnostic accuracy to 99.999%, I suggest we do it; most likely you feel the same way. Often we won't have time to take it that far, and I guess that's where you are coming from. These numbers are illustrative only; the real numbers are not necessarily that good, in part because our tests and methods have their limitations even if they were applied perfectly.

More to the point of the OP's question, I'm not quite sure why it is so hard to see that the original question asked "What tests do you order, what do you do now, and would you make a Dx or DDx." I copied and pasted that from the original message. it's pretty clear that there are a few roads that can be traveled here, and at least one of them involves a DDx and waiting for more information before you do the Dx. It doesn't really matter if your school or instructor wants one thing if that's not what this student's instructor wants. I have personally had points taken off when I had the correct diagnosis and treatment plan for a case exercise because I didn't explore some parts of my DDx that were obviously not applicable based on the case presentation because my attending wanted students to fully explore the DDx in great detail just to go through the motions and develop the skill; students who never had the corrected Dx on their DDx got full credit because they did go through the motions. Getting the right diagnosis or treatment plan was less (or even not) important for the grade in those exercises.

 

[smq123]

I think we ought to at the least check for carotid bruits. He has HTN and an elevated lipid panel, which would give him increased risk for carotid stenosis, no? Besides, it takes all of 15 seconds to do so what does it hurt?

The OP was specifically asking for lower abdominal bruits - femoral, iliac, popliteal, etc. I'm sure as heck not going to waste time listening for a popliteal bruit....and I'm not even sure that I remember how to listen for a femoral bruit (if I ever knew in the first place!)

If you'd want to check for carotid bruits, knock yourself out. (In all honesty, if confronted with a real patient like this, I'd probably listen for carotid bruits, too.)

Omg, this thread makes me want to throw up. For f*c&'s sake, the patient has stage 1 HTN and is showing signs of LVH (high volt QRS, S4 from stiff ventricle) and end-organ damage (fundoscopic exam).

It certainly does bring back traumatic memories of internal medicine daily didactics and PBL.

I have personally had points taken off when I had the correct diagnosis and treatment plan for a case exercise because I didn't explore some parts of my DDx that were obviously not applicable based on the case presentation because my attending wanted students to fully explore the DDx in great detail just to go through the motions and develop the skill; students who never had the corrected Dx on their DDx got full credit because they did go through the motions.

This is what irritates the f*** out of me. (Obviously, this has nothing to do with you, but just pre-clinical medical education in general.)

WHY do people insist on such a slow, leisurely approach to making a DDx? And going through it in such great detail? For the first few times, sure, that's fine. But it got to the point where you try to hurry it up, or suggest reasons why things shouldn't really be on your DDx to begin with, they'd stop you or tell you to "slow down."

I honestly do NOT believe in having a long-ass DDx just for the sake of having a long DDx. Some symptoms do NOT merit a long DDx.

This approach sets you up for a steep learning curve come 3rd year, when you suddenly, on the fly (and on your own) have to develop the ability to make a mental DDx in your head, and then QUICKLY eliminate the impossibles or the incredibly rare diagnoses. And then, equally quickly, figure out how to further narrow your DDx. Teaching you how to be through is important, but it's also important that they NOT teach you how to be comically slow.

The main reply I have is that if you misdiagnose the patient's ailment and no one ever finds out at your school/hospital (and you diagnosed something reasonable based on the symptoms, etc.) you get to continue on your merry way. That 1 in 1000 person that you might potentially misdiagnose by playing odds might not live so happily ever after. I truly appreciate the joy of a diagnosis that is right 99.99% of the time. However, if there is something fairly easy and inexpensive that we can do (*and* have the time and money to do) to bring that diagnostic accuracy to 99.999%, I suggest we do it; most likely you feel the same way.

Oh my sweet Jesus, you're going to hurt your patients so much.

Chasing zebras (which med schools LOVE to teach their MS2s to do) is NOT a benign process. No matter how much you'd like to believe that it's more important to get a correct diagnosis, sometimes....it just isn't.

In order to rule out all the rare causes that might possibly cause HTN, you'd have to subject your patients to 24 hour urine collections, multiple CTs (which also, by the way, subject your patient to a fair amount of radiation), multiple MRIs, multiple CTAs, renal ultrasounds, a sleep study, dexamethasone-suppression tests, exotic (and expensive) lab tests, etc, etc.

Should you subject ALL patients to these tests, just to catch any unusual cases of HTN? Or just the patients that don't seem to be responding to the initial, basic, run-of-the-mill treatments?

You have to pick the most likely one or two things to treat, to start with. And then, if the patient doesn't seem to respond and get better, THEN get more complex. And this is another thing that all your MS3 attendings seem to expect you to intuitively know/understand, but is something that your MS2 professors NEVER teach you.

 

[45408]

Maybe check an echo to see the extent of heart dysfunction.

Maybe spend $3000 cuz you're curious....

I don't see a reason to do an echo.

 

[LadyWolverine]

Chasing zebras (which med schools LOVE to teach their MS2s to do) is NOT a benign process. No matter how much you'd like to believe that it's more important to get a correct diagnosis, sometimes....it just isn't....

You have to pick the most likely one or two things to treat, to start with. And then, if the patient doesn't seem to respond and get better, THEN get more complex. And this is another thing that all your MS3 attendings seem to expect you to intuitively know/understand, but is something that your MS2 professors NEVER teach you.

This is where the disconnect is gonna be between the current MS2s and the clinical years students. Most of us started off our rotations with H&Ps and assessments that contained rather thorough differentials, mainly because we didn't yet realize what was important/relevant/likely, and what wasn't, and we were terrified of missing anything. And 6 months into my 3rd year, I still don't always know. What I am acutely aware of is the time crunch that is modern medicine in this country, and the majority of my attendings would probably just cut me off in mid-presentation if I went through the entire ddx every time someone presented with HTN, or chest pain, or abd pain, or a fever. I DO, however, think it's a worthwhile exercise to go through it ON YOUR OWN, especially for more "vague" sx/signs, the first few times you see them. Then, you start to get more comfortable with 2 or more s/s at once, and you develop a sort of "flow-chart" way of thinking. Pretty soon you start picking up what things are important to include in the presentation/assessment, and what can be left out. I'm still waiting for my "Eureka!" moment most of the time, but at the very least, I've start to recognize patterns.

As a matter of fact I presented a guy this morning in outpatient clinic who came in for high BP and edematous, itchy legs (which ended up being secondary to chronic venous stasis). I DID go through the ddx for what the skin changes in his extremities could have been due to. But for HTN, I just mentioned that as a second bullet point in my problem list, and assumed that it was essential. I gave him some lasix and lisinopril (no HCTZ given his h/o gout) and sent him on his merry way. No fancy tests for cushings or RAS.

Oncocap, there's just not enough time and resources and it's unrealistic to use these as screening tests for everyone who walks in the door with HTN (except for a good physical exam, of course). That extra 0.001% of diagnostic accuracy becomes hard to justify in practice when you think in terms of time, cost, etc. Your best bet in most cases is to treat the most likely cause, and if there is no response in a decent amount of time, then zero in on the other "hooved mammals."

 

[LadyWolverine]

I don't see a reason to do an echo.

See, this is why I'm still a 3rd year. I'm not certain at what point an echo is deemed necessary. When there's an S4? An S3? When the heart becomes a certain size on CXR? When there are signs of left heart failure? When the patient has bilateral pitting edema to mid-thigh? I'm sure there are multiple indications and some clinicians' thresholds are different than others.

To be honest I vaguely remember the original question. I could stop being lazy and go look at it again, I guess.

 

[OncoCaP]

The OP was specifically asking for lower abdominal bruits - femoral, iliac, popliteal, etc. I'm sure as heck not going to waste time listening for a popliteal bruit....and I'm not even sure that I remember how to listen for a femoral bruit (if I ever knew in the first place!)

If you'd want to check for carotid bruits, knock yourself out. (In all honesty, if confronted with a real patient like this, I'd probably listen for carotid bruits, too.)



It certainly does bring back traumatic memories of internal medicine daily didactics and PBL.



This is what irritates the f*** out of me. (Obviously, this has nothing to do with you, but just pre-clinical medical education in general.)

WHY do people insist on such a slow, leisurely approach to making a DDx? And going through it in such great detail? For the first few times, sure, that's fine. But it got to the point where you try to hurry it up, or suggest reasons why things shouldn't really be on your DDx to begin with, they'd stop you or tell you to "slow down."

I honestly do NOT believe in having a long-ass DDx just for the sake of having a long DDx. Some symptoms do NOT merit a long DDx.

This approach sets you up for a steep learning curve come 3rd year, when you suddenly, on the fly (and on your own) have to develop the ability to make a mental DDx in your head, and then QUICKLY eliminate the impossibles or the incredibly rare diagnoses. And then, equally quickly, figure out how to further narrow your DDx. Teaching you how to be through is important, but it's also important that they NOT teach you how to be comically slow.



Oh my sweet Jesus, you're going to hurt your patients so much.

Chasing zebras (which med schools LOVE to teach their MS2s to do) is NOT a benign process. No matter how much you'd like to believe that it's more important to get a correct diagnosis, sometimes....it just isn't.

In order to rule out all the rare causes that might possibly cause HTN, you'd have to subject your patients to 24 hour urine collections, multiple CTs (which also, by the way, subject your patient to a fair amount of radiation), multiple MRIs, multiple CTAs, renal ultrasounds, a sleep study, dexamethasone-suppression tests, exotic (and expensive) lab tests, etc, etc.

Should you subject ALL patients to these tests, just to catch any unusual cases of HTN? Or just the patients that don't seem to be responding to the initial, basic, run-of-the-mill treatments?

You have to pick the most likely one or two things to treat, to start with. And then, if the patient doesn't seem to respond and get better, THEN get more complex. And this is another thing that all your MS3 attendings seem to expect you to intuitively know/understand, but is something that your MS2 professors NEVER teach you.

Yes, I also wish that we were taught early on that sometimes you need to work quickly with minimal information and how to approach that. Early on, we literally were forbidden to use abbreviations like PE, Hx, HTN. Everything had to be written out. Efficiency is very important and doesn't get much airtime early on.

If they want to take off points because I didn't ask my patient if he had a parakeet to rule out C psittaci on a common cold presentation, so be it. Life goes on. Nearly all attendings I have met are very reasonable and didn't give me a hard time about that kind of thing.

With the hypertension, I look at it a little bit differently. Chances are this patient is going to be on this med for many years, assuming he or she is compliant. I'm a bit more interested in making sure I get that right. I have a friend who has hemochromatosis that was never diagnosed in the 20 years he went to physicians about his various problems related to that. Nice guy in his 40s with a couple of kids. Totally disabled now because no one ever took the time so say, hey, you look kinda tan for a white guy. I see you have all these symptoms. I know this is a long shot, but let's run an iron panel just to be sure hemochromatosis. Even after he figure out what he had on his own, it took several trips to physicians before anyone would even listen to him and take him seriously. By then his liver was shot, he had diabetes, and his heart was messed up also. I know you can't help everyone, but a little well placed effort pays off sometimes. If I have the time, I want to know my patient can afford the copay for the medicine I'm prescribing. Again, if I have the time (and it doesn't cost too much), I'm willing to make sure that person's HTN isn't due to some renal problem by running whatever labs our service considers acceptable maybe "urine for protein and blood; serum creatinine (estimated glomerular filtration rate [GFR]) and electrolytes; fasting blood glucose; fasting lipid profile." If a particular test is very expensive or a big hassle, I would consider an alternative or realize that it's not practical in this case. I see it as a balancing act between working quickly and trying to be as thorough as possible in the time allowed. If my attending didn't want me to spend more than a minute with the HTN patients, I'd be willing to do whatever the attending wants, even write for HCTZ off the vitals and a quick general appearance to make sure the person didn't look sick. I'm not saying that this is my preference, just that I'm willing to adapt to my surroundings. We live in an imperfect world and we need to do the best we can under the circumstances. In a classroom, that means finding out what the instructor wants and giving them that, no matter how pointless it seems. We had an ID doctor that really liked gram stains and antibiotic resistance profiles. If you even thought about recommending an antibiotic without checking resistance on a outpatient at a walk-in clinic, you were going to be made an example of. If your patient had sputum, you had better recommend the gram stain right off the top or you were going to get that question wrong. If I'm in a clinic, I'll do what works there, which is different from class in many ways. We get to have some patient exposure our first couple of years. It's not every day, but usually every other week. It's not unusual to get to spend more than an hour with some patients, asking for a detailed history, doing all kinds of physical exam procedures. Sometimes I would sit in and listen to a dietitian or a nephrologist come by and do their thing. We had lots of time. I know this will change, but we actually were able to spend many hours with patients on a regular basis. It was pretty fun.

 

[smq123]

I DO, however, think it's a worthwhile exercise to go through it ON YOUR OWN, especially for more "vague" sx/signs, the first few times you see them. Then, you start to get more comfortable with 2 or more s/s at once, and you develop a sort of "flow-chart" way of thinking. Pretty soon you start picking up what things are important to include in the presentation/assessment, and what can be left out.

No, I agree completely.

I just don't like the way that it tends to be done in most schools, where it truly is more an exercise in "mental ma*turba****," than anything else.

See, this is why I'm still a 3rd year. I'm not certain at what point an echo is deemed necessary.

Well, you get an echo whenever you think it would show you something useful.

In the guy above, it seems pretty clear that he has LVH. And that's all. He doesn't have any chest pain, no angina, no real problems going up stairs or walking any significant distance (at least, I assume that he doesn't). He doesn't have signs or symptoms of wall abnormalities, excessively small ventricles, or valvular disease (in which case you'd also consider a TEE).

Basically, don't get it unless you really think that the test will show you something different, or something that will affect your management plan.

 

[OncoCaP]

Maybe spend $3000 cuz you're curious....

I don't see a reason to do an echo.

Just auscultate the abdomen and back near the kidneys for bruits. Cost $0.

It also makes me mad how much they charge for these procedures. We can't just have a simple echo to catch 95% of the problems. No, we need a machine that can count the number of endothelial cells between the kidney and aorta and we always gather a bunch of data that we don't need. I can't wait until they come out with a handheld U/S scanner that I can just put in my pocket to do my own screening when the full-blown thing is not warranted (esp. for the heart). Heck I wouldn't mind a handheld ECG machine and use it the way I use a fever temp scanner ... and run a quick 1 minute scan on the heart they way they check BP routinely. I wouldn't charge the patient a dime. I would just use it to catch things we would otherwise miss because the full-blown test is not warranted and these machines are very fast. I know I wouldn't be allowed to use that just anywhere, but some services might not care.

 

[Droopy Snoopy]

I can't wait until they come out with a handheld U/S scanner that I can just put in my pocket to do my own screening when the full-blown thing is not warranted (esp. for the heart). Heck I wouldn't mind a handheld ECG machine and use it the way I use a fever temp scanner ... and run a quick 1 minute scan on the heart they way they check BP routinely. I wouldn't charge the patient a dime. I would just use it to catch things we would otherwise miss because the full-blown test is not warranted and these machines are very fast. I know I wouldn't be allowed to use that just anywhere, but some services might not care.

Here you go:

 

[smq123]

I'm a bit more interested in making sure I get that right. I have a friend who has hemochromatosis that was never diagnosed in the 20 years he went to physicians about his various problems related to that. Nice guy in his 40s with a couple of kids. Totally disabled now because no one ever took the time so say, hey, you look kinda tan for a white guy. I see you have all these symptoms. I know this is a long shot, but let's run an iron panel just to be sure hemochromatosis.

<sigh>

One of the moderators in the anesthesia forum is JetPropPilot - who, despite being very colorful and having several unique posting idiosyncracies, truly seems like a great attending that has a lot to teach. In one thread in that forum, he wrote:

recognize that your section chief is perpetuating what I'm fighting against:

MOULDING RESIDENTS BASED ON THEORY AND ZEBRAS.

Yes, you need to be aware of the zebras, and act accordingly when they present.

But you shouldnt be taught to mould your practice based on theory and zebras.

While his example was geared specifically towards residents, it's an excellent summary of what is so frustrating about MS1 curriculums. They often spend so much time on the zebras that they often bias their students towards the zebras as well...and then they find that they know very little about the "bread and butter" problems that they encounter in clinical practice.

And, if you think about it, relentlessly chasing down zebras is kind of selfish. Patients want answers - no matter how you try, explaining to them why they need 7 different lab tests to rule out 7 fairly rare conditions is not going to help. It's worse with something like HTN where there often aren't any overt symptoms - "I feel fine. I don't feel sick. So why is he wasting so much time doing so many stupid and expensive tests? Screw him, he's an idiot and doesn't know what the hell he's doing. I'm leaving." While, in a minor way, you're doing all those lab tests for them, it doesn't really help them - it's more likely a huge turn-off, and may drive them away from the healthcare system altogether.

We get to have some patient exposure our first couple of years. It's not every day, but usually every other week. It's not unusual to get to spend more than an hour with some patients, asking for a detailed history, doing all kinds of physical exam procedures. Sometimes I would sit in and listen to a dietitian or a nephrologist come by and do their thing. We had lots of time. I know this will change, but we actually were able to spend many hours with patients on a regular basis. It was pretty fun.

Yeah, it will. <sigh>

 

[smq123]

Just auscultate the abdomen and back near the kidneys for bruits. Cost $0.

That's not what an echo checks for.

 

[LadyWolverine]

With the hypertension, I look at it a little bit differently. Chances are this patient is going to be on this med for many years, assuming he or she is compliant. I'm a bit more interested in making sure I get that right..

I agree that it's important to get things right, make sure your patients can pay, make sure they are compliant, etc. But sometimes that takes time and several outpatient visits (if FM or outpt IM is your bag) to find the right regimen, get a response, come in for follow-up labs/BP checks, optimize dosage, etc. The same goes for any chronic condition, be it diabetes, depression, whathaveyou. But, as it has been said before, the way to go about this isn't to throw the book at the guy walking in the door. You can't overwhelm your patient with hundreds of tests that he/she has to do - many times, you're lucky if the patient can afford transportation to the appointment, agrees go and get their bloodwork, and then is compliant with medications and follow-up. It takes a HUGE amount of work/paperwork/communication just to manage one chronic condition - many of these patients have several. It is best to take 2 or 3 steps at a time, develop a relationship with that person, and optimize your treatment plans over the long-term. As I said before, if an initial treatment is not successful, then you start to think of some of the more unusual causes.

I have a friend who has hemochromatosis that was never diagnosed in the 20 years he went to physicians about his various problems related to that. Nice guy in his 40s with a couple of kids. Totally disabled now because no one ever took the time so say, hey, you look kinda tan for a white guy. I see you have all these symptoms. I know this is a long shot, but let's run an iron panel just to be sure hemochromatosis. Even after he figure out what he had on his own, it took several trips to physicians before anyone would even listen to him and take him seriously. By then his liver was shot, he had diabetes, and his heart was messed up also. I know you can't help everyone, but a little well placed effort pays off sometimes.

This is unfortunate. It is well-known that hemochromatosis is a relatively common disorder (1:200? 1:300?). It's amazing that this guy went 20 years without a dx. I know that it's often been in my ddx, even though I've never actually seen a case. And I see your point. But, once again, it's about balance. Am I going to get Fe studies on everyone who walks through my door? Probably not. I guess it would depend on the s/s they present with. Maybe you, as a practicioner, will have a higher index of suspicion and will test more frequently, given your experience, and you will catch a case or 2. But sadly, you just can't do that for every disorder out there.

If I'm in a clinic, I'll do what works there, which is different from class in many ways.

Well, that's kind of the bottom line that most of us have been trying to convey.

We get to have some patient exposure our first couple of years. It's not every day, but usually every other week. It's not unusual to get to spend more than an hour with some patients, asking for a detailed history, doing all kinds of physical exam procedures. Sometimes I would sit in and listen to a dietitian or a nephrologist come by and do their thing. We had lots of time. I know this will change, but we actually were able to spend many hours with patients on a regular basis. It was pretty fun.

We also had a lot of "patient exposure" during the first 2 years, very similar to what you describe here. Sadly, it was a bit of a shock to me how much that changes during 3rd year. You simply don't have time to spend an hour with each patient, because you are worried about checking labs, getting hospital records, being on time for rounds/morning report/noon conference, actually working...enjoy the time you get to spend with your patients now.