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Kornhauser Health Sciences Library

Douglas Brown: The Case

Problem Based Learning guide for 2nd Year medical students.

 

The Case

 

HPI:

Douglas Brown is a 43-year-old black male with history of hyperlipidemia, obstructive sleep apnea, obesity, and recent office visits where his blood pressure was elevated. Six months ago, his blood pressure was 153/97. A repeat blood pressure taken 3 weeks later showed his blood pressure to be 157/91. At that time, he wanted to try non-pharmacological options, so you recommended dietary changes, to be tried for 6 months. 

​ROS: Positive for heavy snoring, feeling tired in the daytime, and a headache upon awakening in the mornings.

PMHx: Obesity 

Past Surgical History: None

Medications: None

Fhx:

His father died of a myocardial infarction at the age of 63. His mother has diabetes, hypertension, and hyperlipidemia. He has four adult siblings, all of whom have hypertension.

SHx:

Mr. Brown is married, and has two healthy children, ages 4 and 7. He works as a janitor, does not own any pets, and apart from janitorial work, leads a self-described sedentary lifestyle. He smokes ‘five cigarettes’ per day, drinks alcohol during social occasions, and never more than three servings on any given night. He has never used illicit drugs.

Exam:

Test Value
T 98.1
HR 91
BP 155/92
RR 18
SpO2 96%
BMI 33

General: NAD, obese in habitus, minimal facial plethora

HEENT: normal nasal and throat mucosa, no JVD, eyes clear, neck circumference 18”

Chest:  CTA bilaterally with good air exchange

CV: RRR with normal S1 and pronounced S2, laterally displaced PMI

Abdomen: no organomegaly or tenderness, normal bowel sounds. Central adiposity is present.

MSK: no joint swelling or deformities, normal range of motion

Skin: no rashes, no excoriations

You repeat the blood pressure after having the patient sit for five minutes, with legs uncrossed, in a quiet room, with no talking. His repeat blood pressure is 154/90.

You discuss these results with Mr Brown, and recommend blood pressure medication to help him get his blood pressure under control. He is initially reticent, but you explain some of the issues which can arise with chronically high blood pressure, and he understands how important treatment will be. You start him on hydrochlorothiazide and have him come back in a week for some blood work. His labs from today are normal.

He comes back one week later, with the following labs:

Test Value
Na 134
K 3.4
Cl 96
HCO3 23
BUN 16
Cr 1.12
Ca 10.0

You tell him that he can continue this dose, and that he needs to keep a blood pressure journal. He should take the blood pressure at the same time each day, should never skip medication doses, and should continue to attempt dietary changes and weight loss to further lower his blood pressure and cardiovascular risk scores.

Six months later, Mr. Brown presents for a checkup to your office. He says he’s ‘feeling great’.

His exam is as follows:

Test Value
T 98.7
HR 86
BP 161/94
SpO2 97%
BMI 33

The physical exam is essentially unchanged from the previous exam.

You obtain the following labs: 

Test Value
Na 137
K 3.4
Cl 100
HCO3- 22
BUN 20
Cr 1.3

Urinalysis shows no protein.

You ask to see his blood pressure journal. You notice that his blood pressure has never been controlled on the HCTZ, even after you increased the dosage at the three-month appointment. Review of records shows he is filling his medications as would be expected. He says he is trying to eat a better diet but is very tired when he comes home from work, and neither he nor his wife has time to cook meals. You discuss that he will likely need to be on an additional medication. He expressed disappointment, but agrees. You add amlodipine, and tell him about the possible side effects.


At his six month follow-up appointment, his blood pressure journal shows moderately better readings. His blood pressure averages ~150/100.

Urinalysis shows trace protein.

You add lisinopril. His follow-up blood work one week later shows no rise in Cr. You titrate the medication up to full dose.

Two weeks later, he presents to the emergency room. Below is a representative picture from his physical exam:

patient lips

Visualdx via Uptodate. Internal use only. Do not reproduce.

He is not having trouble breathing. He is watched overnight in the hospital, lisinopril is stopped, and he recovers.

You see him in the outpatient clinic 1 week later and start him on Valsartan, telling him this is a drug that is “cousin” to lisinopril, but without the same side effects. He takes the prescription and thanks you.

Six months later, his blood pressure remains poorly controlled. You start him on a 4th agent. Unfortunately, his blood pressure remains poorly controlled. You then begin a workup to evaluate for a secondary cause of hypertension. 

A CXR is obtained:

Chest Xray

You order a sleep study.  The results return showing Mr. Brown has obstructive sleep apnea, and he is started on nightly CPAP therapy. 

You also order an aldosterone:renin ratio which comes back as normal.

When you notice this, you ask Mr. Brown if he has been taking all of his medications. He sheepishly reports there is one he hasn’t been able to take since it was prescribed to him, because he can’t afford it. You place him on the cheaper version of this medication. After this change goes into effect, you are able to get consistent readings of ~ 130/80. You continue to see Mr. Brown in clinic, and do not order any further workup for his hypertension.

 

Clinical Librarian

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Ansley Stuart
Contact:
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502-852-8534

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