zaki
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A 56-year-old man is seen at the outpatient clinic for routine follow-up of hypertension. He has no complaints but is worried that his blood pressure “may be a little high.” He denies any recent change in health status or drug use. His record shows that he has been prescribed a four-drug regimen of diltiazem sustained-release (SR), 360 mg daily; captopril, 50 mg three times daily; atenolol, 100 mg daily; and hydrochlorothiazide, 25 mg daily. He claims to be taking all his medications. At his last clinic visit 2 months ago, his pulse rate was 68/min, and his blood pressure was 138/86 mm Hg. He has no other known medical problems.
On physical examination, his pulse rate is 86/min and his blood pressure is 194/116 mm Hg (verified in both arms, supine position). The rest of his physical examination is unremarkable as follows: Funduscopic examination shows no evidence of papilledema or hemorrhages. Examination of the heart and lungs is normal. Mental status and neurologic examinations are normal. A stat complete blood count and electrolyte, blood urea nitrogen, creatinine, and glucose levels are all normal. Urinalysis is normal except for trace protein.
At this time, the most reasonable treatment would be:
(A) Administer one dose of captopril and hydrochlorothiazide, and recheck the blood pressure in 1 hour.
(B) Administer nifedipine, 10-mg capsule sublingually.
(C) Administer lorazepam, 1 mg intravenously.
(D) Start a nitroprusside drip, and admit the patient to the intensive care unit.
(E) Instruct the patient to take his medications as usual and return in 2 weeks.
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Maverick
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Choice A
You want to check if he is compliant. No need to give nitro, his BP is <200
He has proteinuria even after being on ACEinhibitor, doesnt seem to be compliant
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| zaki
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Answer: A
Educational Objective: Treat urgent hypertension safely.
The most common cause of accelerated or urgent hypertension is noncompliance with prescribed therapy, despite frequent patient claims to the contrary. Reasonable blood pressure control at the previous visit suggests that the regimen was effective. The fact that the pulse rate is now 86/min casts some doubt on whether the atenolol has in fact been taken recently. Immediate administration of some or all of the patient’s medications will help re-establish that they are in fact effective for this patient. It is not necessary to lower the blood pressure to normal at this juncture. The use of sublingual nifedipine to lower blood pressure has been condemned by medical experts and the Food and Drug Administration. The precipitous and uncontrolled decrease in blood pressure frequently produced by sublingual nifedipine presents a risk of myocardial infarction, stroke, or death. Because the patient has no evidence of acute end-organ damage (papilledema, abnormal mental status or neurologic findings), admission to the intensive care unit for treatment of hypertensive crisis is not warranted. Anxiety is not evident nor is it likely to produce this magnitude of blood pressure elevation; thus, treatment with lorazepam is not indicated. Asking the patient to resume treatment with all medications (option E) is reasonable, but the follow-up period of 2 weeks is unreasonably long. It would be preferable to verify that the patient’s regimen is effective before sending him home
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Maverick
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