here's another case for you

[suckerfree]

27 yo Asian male with CC: having developed a small 1.5" at greatest diameter abscess overlying the right iliac crest. This resolved after a course of Kephlex.

However, on PE there was a finding of elevated BP which was later confirmed on multiple occasions and has been persistently elevated at 140/90. Pt. is slightly overweight with BMI 26, however reports exercising regularly 2-3 x per week with weight lifting and cardio where he raises HR up to 160 for >10 minutes, and denies any family Hx of HTN, HLD, or DM. Pt. reports he is pretty healthy otherwise with no other past medical hx aside from taenia corporis which he has had for 2 years but has not treated it yet.

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[ChildNeuro]

In this young patient with confirmed hypertension I would be concerned about the possibility of a secondary etiology of the hypertension which would include renal parenchymal disease, renal vascular disease, Cushing's syndrome, hyperaldosteronism, hyperthyroidism, alcohol induced hypertension, and oral contraceptive induce hypertension (if this was a female patient). I would get a detailed medical hx, and also social hx and any medications over the counter, herbal that this patient was taking. Initial blood work-up would include a BMP, Phos, Ca, thyroid function test, and urinalysis. Consider the weight gain in this patient, as well as two infections which could be evidence of immune-suppression I would during my comprehensive physical exam take note of the absence or presence of signs of Cushing's syndrome, which in light of his weight gain might lead me to order a 24-hr urine cortisol test during the initial visit as well. I would also consider getting consent for an HIV test.

 

[suckerfree]

I was thinking possibly because this patient had no evidence of Cushingoid facies, characteristic fat redistibution/abdominal striae, etc., and the otherwise benign physical exam that this is possibly a pt. with one of the familial hypercholesterolemic disorders and the high BP was due to atherosclerosis. This case is kind of useless I suppose without the basic labs and a fasting lipid panel, HIV test, etc. I think secondary cause of HTN has to be high on the differential because this patient denied any significant, known family history of cardiovascular disease, etc.

 

[ChildNeuro]

I was thinking possibly because this patient had no evidence of Cushingoid facies, characteristic fat redistibution/abdominal striae, etc., and the otherwise benign physical exam that this is possibly a pt. with one of the familial hypercholesterolemic disorders and the high BP was due to atherosclerosis. This case is kind of useless I suppose without the basic labs and a fasting lipid panel, HIV test, etc. I think secondary cause of HTN has to be high on the differential because this patient denied any significant, known family history of cardiovascular disease, etc.

Oh OK, I thought that the physical exam had yet to be done, and I would look for those factors. I thought that the Family hx. was negative for any hyperlipidemias, but it is always good to consider everything. Don't you know the rest of the case/answer? Weren't you the one who posted this? It would be interesting to know what the best initial tests are, i.e. those that are probably less expensive and/or invasive and will yield useful information.

 

[Adcadet]

First, I'm confused by what exactly we're debating here. The CC listed has now resolved. Seems the new CC is elevated BP, as lame as that sounds as a "complaint." Where did he present to and where is he being seen?

Not sure exactly what you mean by "multiple occasions" and "persistently" and I would like to see a pulse rate along with BPs, but I would have white coat HTN fairly high on my list.

 

[ChildNeuro]

First, I'm confused by what exactly we're debating here. The CC listed has now resolved. Seems the new CC is elevated BP, as lame as that sounds as a "complaint." Where did he present to and where is he being seen?

Not sure exactly what you mean by "multiple occasions" and "persistently" and I would like to see a pulse rate along with BPs, but I would have white coat HTN fairly high on my list.

I don't think that this is a test question, maybe an actual patient someone needs to do a write-up for, a home bp reading would help to exclude white coat hypertension, also maybe a too small sized cuff was used.

 

[suckerfree]

The patient reported having gotten his BP checked on multiple occasions at different times of day in the same R arm, and they had all been around 140/90. I didn't exactly feel like putting up a whole formal H&P seeing as this is an informal discussion board. All other factors on ROS, Vitals, and comprehensive physical exam were WNL. We are still awaiting the blood work results (fasting lipid panel, chem 7, CBC), but without bloodwork, based solely on the history and presentation, I was kind of scratching my head about this in the clinic the other day. I don't normally expect to see HTN, abscesses in an otherwise reasonably healthy 27yo male who reportedly exercises, and no substance abuse, only mildly overweight unless there is something secondary going on.

 

[suckerfree]

The patient reported having gotten his BP checked on multiple occasions at different times of day in the same R arm, and they had all been around 140/90. I didn't exactly feel like putting up a whole formal H&P seeing as this is an informal discussion board. All other factors on ROS, Vitals, and comprehensive physical exam were WNL. We are still awaiting the blood work results (fasting lipid panel, chem 7, CBC), but without bloodwork, based solely on the history and presentation, I was kind of scratching my head about this in the clinic the other day. I don't normally expect to see stage 1 HTN, new onset abscesses in an otherwise reasonably healthy 27yo male who reportedly exercises, and no substance abuse, only mildly overweight unless there is something secondary going on. Perhaps the abscesses are a separate issue, I didn't see anything to make me suspect immunocompromise (HIV negative few months ago, no other infectious symptoms). This patient only reported he had started a new exercise program at the local gym, so I though maybe he picked it up from there. But that was still a stretch. I guess this is bothering my because I don't consider it a typical presentation of HTN.

 

[ChildNeuro]

The patient reported having gotten his BP checked on multiple occasions at different times of day in the same R arm, and they had all been around 140/90. I didn't exactly feel like putting up a whole formal H&P seeing as this is an informal discussion board. All other factors on ROS, Vitals, and comprehensive physical exam were WNL. We are still awaiting the blood work results (fasting lipid panel, chem 7, CBC), but without bloodwork, based solely on the history and presentation, I was kind of scratching my head about this in the clinic the other day. I don't normally expect to see stage 1 HTN, new onset abscesses in an otherwise reasonably healthy 27yo male who reportedly exercises, and no substance abuse, only mildly overweight unless there is something secondary going on. Perhaps the abscesses are a separate issue, I didn't see anything to make me suspect immunocompromise (HIV negative few months ago, no other infectious symptoms). This patient only reported he had started a new exercise program at the local gym, so I though maybe he picked it up from there. But that was still a stretch. I guess this is bothering my because I don't consider it a typical presentation of HTN.

Most important for his health is thoroughly investigate the etiology of his hypertension, if it is real i.e. not white coat, then you should have counciled him about weight loss and more exercise, his caloric intake may be too high. You should read up on the evaluation of hypertension in a young adult, no need to scratch your head just work it up and follow the patient and treat them. The CBC will help, and it can take as long as six months for an HIV test to turn positive, you might want to get hx as to unprotected sex. Patients often present atypically as they aren't considerate enough to read the textbooks. (This is a joke!) The "whole formal" H and P is really quite important in ambulatory medicine when it comes to seeing an new patient for the first time, 80% of the diagnosis is in the history. Details count *alot* here, and really in all patient encounters, realize now that you are adding new information saying that this patient has had multiple abscesses, important to nail down would be a PMHx in childhood of abscesses, sinopulmonary infections, this is a pertinent negative, remember, just because you don't state something in presenting to an attending doesn't mean that all is withing normal limits, you may not have asked the right questions. This may take several appointments to get a feel of this patient, but obviously his HTN should be worked up now. If you typed up the full and complete H and P, and presented it to a good internist, see case discussion in NEJM for how this is done, then they would come up with a list of possible diagnosis and what prudent steps to take next. Alot of diseases in internal medicine present atypically, i.e. if only 10% of MIs present a certain atypical way, but over years of internal medicine residency you will see several of these atypical presentations. . .

 

[carrigallen]

I think that the BP was elevated because the patient was infuriated for having to answer so many questions.

Just schedule him for a follow-up appointment. I doubt that 140/90 merits a workup for secondary HTN. In the same way that a blister doesn't merit a workup for necrotizing fascitis.

 

[ChildNeuro]

I think that the BP was elevated because the patient was infuriated for having to answer so many questions.

Just schedule him for a follow-up appointment. I doubt that 140/90 merits a workup for secondary HTN. In the same way that a blister doesn't merit a workup for necrotizing fascitis.

What does around 140/90 mean, sometimes 145/95? I think that would merit a work-up, doesn't cost to much to at least do a BMP. Even just 140/90 *is* hypertension, both systolic and diastolic, above pre-hypertension. This is important to address in an ambulatory setting, and very importantly to follow the bp, if I had this patient and he didn't improve in three months of diet, say his bp was 142/92 at next visit, standard of care would be to start an anti-hypertensive blood pressure medication, you would probably end up decreasing his risk of other diseases as well. Then ask yourself, how many 27 year olds have a bp of 142/92 or "around there"? Not that many, time to intervene, just because he goes to the gym doesn't mean that he isn't obese or couldn't benefit some weight reduction. In the inpatient setting maybe this bp wouldn't be anything to write home about, but as a pcp you need to be concerned. . . Hypertension is a cut-off, plain and simple, if his bp is real he has hypertension, you treat, and you figure out what is causing it, do the same thing for 100 similar 27 years with elevated bp and you will find some secondary to something else. This is a no-brainer IMHO. *Alot* of people with HTN are not being treated adequately, it costs lives every year, you can't just treat something when you feel like it, a cut-off of greater than or equal to 140/90 is there for a reason, people with 142/90 *DO GET TREATED!!!**

 

[suckerfree]

Repeat blood pressures in the same right arm have confirmed that yes, the BP in this 27 yo male w/ BMI 26 is 140/90.
NA 143
K 5.0
CL 103
CO2 23
BUN 18
CREAT 1.2
GLUC 87
CALCIUM 9.7
ANION GAP 17.0

HDL 56
CHOL 190
TRIG 105
LD LIPO 113 H

TSH 1.07

I'm still not pleased with this at all.

 

[Geri_Gal]

"I don't normally expect to see HTN, abscesses in an otherwise reasonably healthy 27yo male who reportedly exercises, and no substance abuse, only mildly overweight unless there is something secondary going on."

A skin abscess is not that unusual -- was it cultured? Community acquired MRSA has been linked to athletes...no doubt it could be acquired in a gym. This is unlikely due to its response to Keflex.
http://www.health.state.ri.us/disease/communicable/providers_mrsa060705.php

Run of the mill HTN can exist in a 27 year-old. Has BP been checked in the other arm? In the lower extremities? (r/o coarctation) His lipids are not ideal. This guy needs a PCP!

 

[Bike on a Trek]

1) make sure you are using a large adult cuff
2) you could give him a cuff to measure his pressures at home, as they should be lower than what you get in an office by about 5mmHg
3) review meds, including caffeine intake, over-the-counter medications, and any nutritional supplements (esp those associated with his weightlifting)
4) with appropriate technique, listen in a quiet room for a renal bruit

Assuming all the above are fine, he almost certainly has benign essential hypertension and the abscess is unrelated. I would not spend additional money on testing. I would start him on HCTZ 12.5mg/day.

 

[ChildNeuro]

1) make sure you are using a large adult cuff
2) you could give him a cuff to measure his pressures at home, as they should be lower than what you get in an office by about 5mmHg
3) review meds, including caffeine intake, over-the-counter medications, and any nutritional supplements (esp those associated with his weightlifting)
4) with appropriate technique, listen in a quiet room for a renal bruit

Assuming all the above are fine, he almost certainly has benign essential hypertension and the abscess is unrelated. I would not spend additional money on testing. I would start him on HCTZ 12.5mg/day.

I think the first step in management would be weight loss i.e. more exercise, eat a little less and re-check bp in three months, no need to start him on a medication if you can fix it with diet. I would also do a UA, his electrolytes are creeping up, i.e. K near upper limit of normal, Na near upper limit of normal . . . And a BMI of 26 is overweight if I am not mistaken, so exercise in his case could help. I would also ask him to decrease his intake of salty foods, . . .

 

[Bike on a Trek]

I think the first step in management would be weight loss i.e. more exercise, eat a little less and re-check bp in three months, no need to start him on a medication if you can fix it with diet. I would also do a UA, his electrolytes are creeping up, i.e. K near upper limit of normal, Na near upper limit of normal . . . And a BMI of 26 is overweight if I am not mistaken, so exercise in his case could help. I would also ask him to decrease his intake of salty foods, . . .

Okay, I'll give you a UA (though likely it will be normal). But, he's already exercising regularly and his BMI is not outrageously "high", especially if he's a weightlifter (e.g., let's say he's 5'9", then a weight of 176 gives him a BMI of 26). You could implement your strategy of emphasizing weight loss and try to exercise even more--that wouldn't be wrong at all and waiting 3 months won't harm him. But I have a pretty strong sense that this healthy appearing young man is going to need a low-dose of a thiazide diuretic. And, yes I would counsel him on diet and the cardio part of his exercise, but I'd also given him an Rx of thiazide and tell him if he can lose just a little weight and exercise just a little more, he might be able to eventually stop the thiazide in 3 months. Giving him the Rx for a low dose thiazide certainly has low risk and certainly gives him the message that treating his blood pressure is important.

 

[ChildNeuro]

Okay, I'll give you a UA (though likely it will be normal). But, he's already exercising regularly and his BMI is not outrageously "high", especially if he's a weightlifter (e.g., let's say he's 5'9", then a weight of 176 gives him a BMI of 26). You could implement your strategy of emphasizing weight loss and try to exercise even more--that wouldn't be wrong at all and waiting 3 months won't harm him. But I have a pretty strong sense that this healthy appearing young man is going to need a low-dose of a thiazide diuretic. And, yes I would counsel him on diet and the cardio part of his exercise, but I'd also given him an Rx of thiazide and tell him if he can lose just a little weight and exercise just a little more, he might be able to eventually stop the thiazide in 3 months. Giving him the Rx for a low dose thiazide certainly has low risk and certainly gives him the message that treating his blood pressure is important.

Uh, if you start him on the thiazide *and* ask him to lose weight how do you know which one worked if his bp is lower in three months?! Are you going to take him off the thiazide in three months and the see what happens!?? If you use the excellent guidelines for HTN this well help decide this case, you can't rely on on your "gut instinct" in medicine, you go by the facts. The facts of the case and the recommended management is to try exercise and weight loss first. A incentive to lose weight is to say that if the patient does it then he/she doesn't need to go on a medicine. A person already on the medicine what would you say? I think you need this but I am not sure, so if you want to excercise to get off the pill maybe that will work. Alot of people who say to h*** with excercise for my bp when I can take the pill. I think that exercise would actually work in this patient as he already goes the gym, and he might become fanatical about lowering his bp. The guidelines, which I assume is based on more clinical experience than you or I have, and maybe even evidence based medicine, says to go for the exercise and weight control. Also, asking a patient to exercise/eat less to avoid a medication for bp DOES tell the patient you care about their bp. You cant go with gut feelings, what if you get a patient that has tachycardia, dyspnea, normal CXR but you don't feel that they have a PE?!? Medicine is about using alogorithms and exploring all possibilities, not guessing what might work . . . I would correct you viewpoint if you made it to group of students regardless of whether you are a student or resident. Interestingly there are some cases where you would go straight to medications, . . . students often look at lab value or other info like BMI and say, well it is almost normal, so I guess I don't have to worry about it. This patient's BMI is *clearly* overweight so excercise/weight loss should help, you shouldn't say he is almost normal, the line has been drawn based on many factors, and you should adjust ranges to suit your own gut feelings about a patient. Please re-read what the literature has to say about treatment of newly discovered hypertension.

 

[souljah1]

Are we really discussing the optimal management of 140/90 in someone with a BMI of 26??

A BMI of 26 is technically "overweight" and by this categorization Payton Manning is overweight. Tell him to go exercise more. What is actually more useful is waist circumference. BMI underestimates adiposity in Asians and overestimates adiposity in blacks. A BMI of 26 has to be interpreted in the context of the patient. Show me a mortality difference between a BMI of 25 and 26 in a man in his 20's....

A blood pressure of 140/90 is barely hypertension and in someone who is his age you can throw is a** on the DASH diet if he's down and maybe encourage a bit more exercise. Oh boy, he could have renal artery stenosis or Conn's Syndrome or von hippel lindau with a pheo or blah blah blah. He has HTN. Common things being common, he has essential hypertension (which isn't all that uncommon in our society). Secondary hypertension is usually higher than this. I wouldn't put him on any meds for this BP unless he was a sloth and failed at a go of "lifestyle modifications".

 

[Bike on a Trek]

U....I think that exercise would actually work in this patient as he already goes the gym, and he might become fanatical about lowering his bp. The guidelines, which I assume is based on more clinical experience than you or I have, and maybe even evidence based medicine, says to go for the exercise and weight control. Also, asking a patient to exercise/eat less to avoid a medication for bp DOES tell the patient you care about their bp. You cant go with gut feelings, what if you get a patient that has tachycardia, dyspnea, normal CXR but you don't feel that they have a PE?!? Medicine is about using alogorithms and exploring all possibilities, not guessing what might work . . . .

Yes, the guidelines recommend diet and exercise--that would be the textbook answer and the answer you would use on outpatient/inpatient clinical rounds. I am not at all dismissing this. However, we always wind up using our heads and making recommendations in view of the guidelines. You've gone with your gut when you write "I think exercise would actually work in this patient as he already goes...." The problem with getting a case like this is that you don't get an appreciation for the reality of the patient. Your dismissal of "gut feelings" by asking whether I would ignore PE in a patient with tachycardia, dyspnea, and a normal CXR on account of gut feelings is silly--of course I would dismiss PE if I felt strongly the patient was having a panic attack. It's all about context, and the words used to describe a case in a condensed Forum entry such as this can lead us all to infer different sorts of things.

My sense is that this young guy is already exercising pretty regularly and that there might be marginal benefit to exercising even more. Maybe a diet would be effective, but maybe he already has a healthy diet and his BMI is up because he is muscular (we need more information). Do the Guidelines we all know about really speak to the amount of benefit you get when taking a person who is already exercising, and then exercise them more?--most of the benefit in exercising accrues to those who are already sedentary. He would experience benefit from more exercise, but it might take a whole lot more exercise with a big impact on lifestyle (in fact, I know quite a few long distance marathoners who are on thiazides for hypertension). So, I certainly don't dismiss going to "more" exercise and diet for this INDIVIDUAL patient. It is TOTALLY appropriate. My suspicion, however, is that he already has "done" diet/exercise. If he truly has effectively already done diet/exercise, then my hunch remains that this patient is truly hypertensive and that HCTZ 12.5mg is one of the more benign interventions we do. I would have no problems with suggesting to this particular patient the strategy of exercise/weight loss and then come back to me in 3 months, but I'm inclined to offer my strategy of exercise/weight loss PLUS HCTZ 12.5mg and come back to me in 3 months where I would recommend stopping the HCTZ if he has increased his exercise, changed his diet, and lost weight. I'd give him the choice of the two strategies.

 

[ChildNeuro]

Yes, the guidelines recommend diet and exercise--that would be the textbook answer and the answer you would use on outpatient/inpatient clinical rounds. I am not at all dismissing this. However, we always wind up using our heads and making recommendations in view of the guidelines. You've gone with your gut when you write "I think exercise would actually work in this patient as he already goes...." The problem with getting a case like this is that you don't get an appreciation for the reality of the patient. Your dismissal of "gut feelings" by asking whether I would ignore PE in a patient with tachycardia, dyspnea, and a normal CXR on account of gut feelings is silly--of course I would dismiss PE if I felt strongly the patient was having a panic attack. It's all about context, and the words used to describe a case in a condensed Forum entry such as this can lead us all to infer different sorts of things.

My sense is that this young guy is already exercising pretty regularly and that there might be marginal benefit to exercising even more. Maybe a diet would be effective, but maybe he already has a healthy diet and his BMI is up because he is muscular (we need more information). Do the Guidelines we all know about really speak to the amount of benefit you get when taking a person who is already exercising, and then exercise them more?--most of the benefit in exercising accrues to those who are already sedentary. He would experience benefit from more exercise, but it might take a whole lot more exercise with a big impact on lifestyle (in fact, I know quite a few long distance marathoners who are on thiazides for hypertension). So, I certainly don't dismiss going to "more" exercise and diet for this INDIVIDUAL patient. It is TOTALLY appropriate. My suspicion, however, is that he already has "done" diet/exercise. If he truly has effectively already done diet/exercise, then my hunch remains that this patient is truly hypertensive and that HCTZ 12.5mg is one of the more benign interventions we do. I would have no problems with suggesting to this particular patient the strategy of exercise/weight loss and then come back to me in 3 months, but I'm inclined to offer my strategy of exercise/weight loss PLUS HCTZ 12.5mg and come back to me in 3 months where I would recommend stopping the HCTZ if he has increased his exercise, changed his diet, and lost weight. I'd give him the choice of the two strategies.

Uh, I think following the guidelines in this patient is a good idea and to start with diet and exercise. It doesn't make sense and is contrary to current standard of practice to start medication in this patient. I would say loudly "Do not start hypertensive as a first step." There are instances where an anti-hypertensivemedication should be started as a first step, this is not one of them. I would advise that you would read the literature. BTW, a patient with PE can have anxiety due to the PE. PE is an often mis-diagnosed condition in internal medicine, and I think most often filed a lawsuit against. Do you know if this guy who is overweight is eating right? He may not be. And he can exercise a little more so he is not overweight. PE CAN CAUSE A LARGE AMOUNT OF ANXIETY!!

Once again, what you are advocating is against current medical practice, you need to read more about hypertension and PE IMHO. I follow the guidelines and showed how my hunches are backed up by the guidelines just to show you how problematic using hunches are. A gut feeling or a hunch could go either way, so what good are they? The standard of care is clear in this case, i.e. mild hypertension, you start diet and exercise. It is naive to write the pt. off because you for cloudy reasons believe he is already doing the best he can. A good rule is that you don't prescribe meds that a patient does not need at the moment, because of side effects and little thing called do no harm. Medicine is more evidence based now, and guidelines are published by authorities on HTN for a good reason, the days of I'm going to do X with this patient because I am guessing this or that are over.

I am continuing on this point for a good reason, there is a logic in medicine that you are not following in your advice to start HCTZ in a young patient with mild-hypertension, the best management decision here is diet an exercise as a first step. When you have taken step 2 and 3, and done some intense clinical work you will understand the difference between the best management choice and doing something that doesn't quite make sense. It makes absolutely no sense to start a bp medicine here, there is no end organi damage, etc . . . in patient who has a good chance of not needing the medication in the first place, a waste of money, patient's time, and run the risk of side effects. Would you start a patient with a breast mass on breast CA chemo before the results of the biopsy? No. You can jump ahead in algorithms without going through important first steps, on the HTN algorithm for mild HTN this means diet and exercise!

 

[souljah1]

Childneuro,

That might have been the single most redundant post I've ever read. All you had to say was, "I disagree, you should not start HCTZ and you should stick with lifestyle modifications per the guidelines". Also, no need for the subtle insults just b/c someone wants to move towards HCTZ in someone who is already exercising. There is no real right answer. Guidelines aren't laws, they are guidelines that should be considered in the CONTEXT of the patient.

And..

Just curious, how do YOU rule out PE in someone with tachypnea, anxiety and tachycardia?? Would you get a d-dimer on every patient that presents in this fashion? Hit them with contrast? Nuclear study? Doppler their legs? Or would you rule it out with a good history and physical --> which is the same thing as a hunch.

On a different note, clinical hunches actually have good pretest probability in certain situations i.e. Does this patient with dyspnea have CHF - or- Does this patient with ESLD whose creatinine has doubled and is now 3.2 have Type 1 HRS? Clinical hunches are often incredibly useful (though less for interns than seasoned clinicians) and often reinforce the clinical usefulness of many preliminary studies. I would disagree that clinical hunches are opposed to "evidence based guidelines".

 

[Gastrapathy]

I would disagree that clinical hunches are opposed to "evidence based guidelines".

Umm...I'm not sure what you mean by "opposed" but there is a huge difference between the diagnosis of HRS and management of Stage I HTN. Your clinical impression (ie hunch) is appropriate to use in the former because of the lack of good evidence for any particular approach and the fact that to even entertain that diagnosis requires one to be a fairly advanced and experienced practitioner.

Now, HTN, on the other hand, should always be managed according to the JNC7 unless there are compelling reasons that the guidelines don't apply to a given patient. There is powerful evidence for nearly all of their recommendations. This patient DOES NOT need a w/u for secondary HTN except for the standard tests that all patients with newly diagnosed HTN should have: H&P looking for underlying illness (OSA, Cushings, drugs, pheo, thyroid dz, etc), lifestyle and other risk factor assessment, and evidence of end-organ damage at time of diagnosis. This includes an EKG, CBC, chemistry, UA and lipids. Then start a thiazide and make lifestyle recs.
Honestly, I hope the OP is the actual patient and not someone looking to get out of work.

The JNC7 Express is 35 pages. Read it. That's all any medicine resident really needs to know about HTN. http://www.nhlbi.nih.gov/guidelines/hypertension/express.pdf

 

[Bike on a Trek]

Uh, I think following the guidelines in this patient is a good idea and to start with diet and exercise. It doesn't make sense and is contrary to current standard of practice to start medication in this patient. I would say loudly "Do not start hypertensive as a first step." .....

My hunch is that this patient with Stage 1 hypertension has already failed the first step, which I inferred from the history that the patient has had multiple occasions of his blood pressure being elevated. Part of this hunch is an assumption that someone has been checking the blood pressures and giving him advice. My visual impression of this patient is that he is a healthy looking, muscular and fit guy. I did recommend confirming that the blood pressures are being taken correctly (part of the guidelines) and possibly giving him a blood pressure cuff to make measures at home, along with confirming OTC meds or supplements as a contributing factor.

Maybe he has tried diet, and maybe not. I definitely agree and practice according to the Guidelines. My SDN name isn't "Bike on a Trek" by accident. At some point, you decide whether or not to recommend adding a thiazide to lifestyle modifications. My hunch, then, is based on what I think this patient looks like and how he already is behaving; in other words, I suspect that the patient may already be failing the first step of lifestyle modifications. Your suggestion that he come back in 3 months isn't really evidence-based in terms of the timing, it's also a hunch. I think it is a reasonable plan to bring him back in 3 months to reassess, but neither you or I know if 3 months is long enough to decide if this young guy will stick to a DASH diet and increase his exercise to daily. There is NOTHING wrong with having a discussion with the patient about his preferred strategy, including the one I'm suggesting which is based on whether I think he's done what is tolerable to him in terms of lifestyle. Whatever the case, Lifestyle modification is not trumped by thiazides, as lifestyle modification should continue when you start a thiazide It would be nice if the Presenter of the case gave us a little more information, or followup. I'd be happy if he accepted your advice, but not surprised if he opted to start a thiazide after counseling and education about the needed lifestyle changes and his likelihood of complying.

BTW, loved your comment ".....When you have taken step 2 and 3, and done some intense clinical work you will understand the difference between the best management choice and doing something that doesn't quite make sense."

 

[Vision]

Um... is it me or the anion gap of 17 should be your primary concern?

who cares about the damn blood pressure, the guys gap is 17!!! with Cl of 103!!!!!

Repeat blood pressures in the same right arm have confirmed that yes, the BP in this 27 yo male w/ BMI 26 is 140/90.
NA 143
K 5.0
CL 103
CO2 23
BUN 18
CREAT 1.2
GLUC 87
CALCIUM 9.7
ANION GAP 17.0

HDL 56
CHOL 190
TRIG 105
LD LIPO 113 H

TSH 1.07

I'm still not pleased with this at all.