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IN ORDER TO ANSWER THE QUESTIONS YOU HAVE TO READ ENTIRED CASE STUD. 

You are required to answer all the DISCUSSION QUESTIONS listed below in each domain.

DOMAIN: HISTORY
1a) Identify two (2) additional questions that were not asked in the case stud and should have been?
1b) Explain your rationale for asking these two additional questions.
1c) Describe what the two (2) additional questions might reveal about the patient’s health.

DOMAIN: PHYSICAL EXAMM
For each system examin in this case;
2a) Explain the reason the provider examin each system.
2b) Describe how the examm findings would be abnormal based on the information in this case. If it is a wellness visit, based on the patient’s age, describe what examm findings could be abnormal.
2c) Describe the normal findings for each system.
2d) Identify the various diagnostic instruments you would need to use to examin this patient.

DOMAIN: ASSESSMENT (Medical Diagnosis)
Discuss the pathophysiology of the:
3a) Diagnosis and,
3b) Each Differential Diagnosis
3c) If it is a Wellness, type ‘Not Applicable’

DOMAIN: LABORATORY & DIAGNOSTIC TESTS
Discuss the following:
4a) What labs should be ordered in the case?
4b) Discuss what lab results would be abnormal.
4c) Discuss what the abnormal lab values indicate.
4d) Discuss what diagnostic procedures you might want to order based on the medical diagnosis. 
4e) If this is a wellness visit, discuss what the U.S. Preventive Taskforce recommends for patients in this age group. 

I HAVE ATTACHED THE CASE STUD TO THIS POST. PLEASE USE APA STYLE REFERENCES AND NO LATER THEN 5 YEARS AGO. 

CASE STUDY: CARDIO

You are working in a free clinic staffed by student volunteers. The clinic has students from multiple disciplines, including medical, nursing, nutrition, social work, and pharmacy students, who all work side-by-side to provide care for uninsured or underinsured residents of the local urban underserved community.

Dr. Gabriela Medel, your supervising family medicine preceptor, discusses your next patient with you and Carla George, a nursing student with whom you are working.

Dr. Medel tells you and Carla, “Mr. Jose Martin is a 54-year-old male who is new to the clinic and has not received medical care in over 10 years.”

Carla offers to take Mr. Martin’s blood pressure.

Carla reports to you and Dr. Medel, “Mr. Martin’s blood pressure is 150/85 mmHg in his right arm, and his pulse is 80 beats per minute. So it appears that we will be considering whether Mr. Martin has hypertension or not.”

You recall that you recently read an article about hypertension, and that guidelines for its definition and treatment have changed over time. You mention this, and Dr. Medel responds, “For many years, we defined blood pressures between 120-139/80-89 as ‘prehypertensive and those over 140/90 or higher as hypertensive.’ Blood pressures in the prehypertensive range were recognized to put people at higher risk of cardiovascular events, and physicians were supposed to give patients with prehypertension guidance on making changes to their diet and exercise to prevent the development of hypertension.

“Physicians and patients often disregarded this label. In 2017, guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA), changed the definition of hypertension to be a blood pressure of 130/80 or higher, which could encourage physicians and patients to focus sooner on the importance of lifestyle changes.”

You ask Dr. Medel, “Am I recalling correctly that the AAFP (American Academy of Family Physicians) did not endorse these guidelines? How do you decide which guidelines to follow in your practice if organizations disagree?”

Dr. Medel replies, “That is one of the challenging things about clinical practice. You’re right—the AAFP still endorses the 8th Joint National Committee (JNC8) guidelines from 2014 with respect to diagnosing hypertension at a blood pressure of 140/90 or greater. After reviewing the newer ACC/AHA guidelines, I did choose to adopt them into my clinical practice. The AAFP pointed out that these guidelines did not fully address the risk of harms with lower blood pressure goals, and so I am more cautious about the potential downsides of lower blood pressures than the ACC/AHA guidelines suggest (especially in groups such as older adults, who are particularly at risk of adverse events from medications). I am also always cautious about conflicts of interest, which was another concern of the AAFP, and will be looking out for further studies that may change these recommendations once again. Additionally, in 2020, the International Society of Hypertension (ISH) released Global Hypertension Practice Guidelines which were developed to reduce the global burden of raised hypertension. These guidelines were intended to be relevant to both low and high resource settings (they recognize that not all settings, including some low resource areas within high income countries, are able to adopt optimal guidelines due to various obstacles including access to medications, follow-up, and/or blood pressure devices). What’s more, these guidelines were developed with input from experts in different regions of the world, making them potentially more applicable to the variety of settings in which we all practice. With regard to diagnosis, the ISH recommends using an average threshold of 140/90 mmHg for office diagnosis of hypertension, but 135/85 mmHg for home and 130/80 for 24-hour ambulatory monitoring. The ISH guidelines also reinforce the importance of lifestyle modifications for the treatment of hypertension, suggesting the consideration of lifestyle interventions for 3-6 months before beginning medication in patients with grade 1 hypertension and no comorbidities.”

You and Dr. Medel discuss the criteria for diagnosing a patient with hypertension.

TEACHING POINT

Causes of Hypertension

95% to 98% of hypertension diagnosed in the United States is essential hypertension—high blood pressure without a secondary cause.

Hypertension with a specific identifiable cause is far less common and is known as secondary hypertension. Testing for secondary causes of hypertension is appropriate if hypertension increases in severity, has a poor response to treatment, or if a patient has a history or physical exam findings that point to a secondary cause.

TEACHING POINT

Criteria for Diagnosing Hypertension

In order to accurately diagnose a patient with hypertension, at least two elevated measurements—five minutes apart, one in each arm—should be made on two or more visits. This is often difficult to achieve in a busy medical practice, so it is important to double-check before definitive diagnosis or making a recommendation for treatment. As noted previously, the USPSTF also recommends obtaining measurements outside of the clinical setting for diagnostic confirmation before starting treatment.

A patient cannot be diagnosed with hypertension if the patient is acutely ill or in acute pain at the time of the measurement.

The measurements are (at least initially) required in each arm because on rare occasions you may encounter an adult with a vascular phenomenon that can cause a pressure difference between the two arms. For example, vascular disease (i.e., plaque) in the subclavian artery can cause a pressure differential, as can aortic dissection. Sometimes, coarctation of the aorta can cause a pressure differential—this is related to the location of the coarctation. Often, the major clinical manifestation of coarctation is a difference in systolic pressures between the upper and lower extremities (higher in the upper, lower in the lower). However, if the left subclavian artery originates distal to the narrowing, the left arm blood pressure may also be diminished relative to that of the right.

It’s time for you to see Mr. Martin. You go to his examination room, introduce yourself, and ask, “How can I help you today?”

Mr. Martin tells you that he came because his wife, Milagros, encouraged him to get “checked out.”

Mr. Martin has not been to a doctor for over 10 years. He says he has been feeling completely fine. He works as a taxi driver for 12-hour shifts, six days a week, so he doesn’t have much time to go to doctors. In addition, his company does not provide him with health insurance. Mr. Martin states that the nursing student seemed concerned about his blood pressure reading today.

“Is my blood pressure too high?” he asks.

“It does seem to be a little high but I’d like to ask you some more questions about your health, examine you, and also recheck your blood pressure before coming to any conclusions.”

You proceed with your interview making sure to include all the questions you just discussed with Dr. Medel and afterward write the following note in the electronic medical record:

PATIENT CHART: HISTORY – MR. JOSE MARTIN

Past Medical History

Mr. Martin reports no history of hypertension, hypercholesterolemia, or diabetes. He reports no history of kidney disease, eye problems, peripheral vascular disease, heart disease, or strokes. No history of gout or arthritis. His last vaccinations were over 10 years ago, and he has not had any preventive services for his age. He reports no other medical problems.

Medications

None. Does not use complementary or herbal remedies.

Past Surgical History

None.

Social History

Mr. Martin speaks English and Spanish. He is married to his wife and has one daughter, age 16. He and his family moved here from the Dominican Republic 10 years ago. He works as a taxi driver for 12-hour shifts, six days a week. His wife works as a seamstress. They are both uninsured. His daughter gets her medical care in her high school clinic. He and his family live in a two-bedroom apartment near the clinic. He is sexually active with his wife only. He does not drink alcohol or use recreational drugs. He does not smoke. The patient has good emotional support from his family and friends. He admits to occasional financial stressors, but his family is never short of food or clothing. However, his daughter may be going to college soon and his rent continues to increase annually, which worries him.

Diet History

Mr. Martin states that he eats a lot of fast food during his long and busy taxi shifts. He eats better when he is at home. His wife makes “chicken without the skin, rice, beans, plantains, yuca, and the occasional marinated pork.”

Family History

His mother, age 73, has high cholesterol and diabetes. His father passed away of a heart attack at age 64. He has no siblings.

ROS:

Constitutional

Mr. Martin reports that he has gained 20 pounds in the past five years. He reports no malaise or fatigue.

Head, Ears, Eyes, Nose, and Throat

He reports no headaches or vision problems.

Lungs

He reports no shortness of breath or other breathing problems.

Heart

He reports no chest pain, palpitations, fainting, or murmurs.

Abdomen

He reports no abdominal concerns.

Genitourinary

He reports no urinary problems or erectile dysfunction.

Extremities

He reports no leg swelling, pain or cramping, or varicose veins.

Neurologic

He reports no weakness, tremors, or other neurologic concerns.

You leave the room for a moment so that Mr. Martin can change into a gown for his physical exam. You consider the aspects of the physical exam you will want to focus on, given Mr. Martin’s potential hypertension.

TEACHING POINT

Important Elements of the Physical Exam in Patients with Hypertension

In general, you want to look for identifiable causes of hypertension, evidence of end organ damage, and signs of cardiovascular disease (CVD).

Body mass index (BMI)

Assess if the patient is underweight, normal weight, overweight, or obese. Being overweight or obese is a risk factor for hypertension, hypercholesterolemia, diabetes, and other diseases.

Fundoscopic eye examination

Assess for arteriovenous nicking, cotton-wool spots, flame hemorrhages, exudates, and other changes associated with hypertensive retinopathy (see diagram), or papilledema associated with hypertensive emergencies. These may be difficult to ascertain in a patient whose eyes are undilated.

Auscultate for carotid, abdominal, and femoral bruits

Assess for the presence of peripheral vascular and cardiovascular disease.

Palpation of the thyroid gland

Assess for nodules, tenderness, or thyromegaly, which might indicate hyperthyroidism, one of the causes of secondary hypertension.

Lung examination

Assess for signs of congestive heart failure, such as crackles or diminished breath sounds. Congestive heart failure can occur with long-standing hypertension, usually over many years.

Heart examination

Assess the heart rate, rhythm, presence of murmurs, or an enlarged point of maximal impulse, which may indicate cardiovascular disease, valvular disease, or cardiomegaly.

Abdominal examination

Look for abdominal aortic pulsation, bruits, or masses.

Lower extremity examination

Assess for the presence of cardiovascular disease or peripheral vascular disease in the lower extremities, such as diminished pulses, loss of extremity hair, thick toenails, cold or red skin.

Conduct a neurologic assessment

Assess for neurologic changes resulting from cerebrovascular disease.

You return to examine Mr. Martin. You get a blood pressure measurement of 151/82 mmHg in the left arm. After your exam, you document the following:

PATIENT CHART: PHYSICAL EXAM – MR. JOSE MARTIN

Vital signs:

· Temperature is 37 °C (98.6 °F)

· Pulse is 80 beats/minute

· Respiratory rate is 18 breaths/minute

· Blood pressure is 150/86 mmHg in right arm. 151/82 mmHg in the left arm.

· Weight is 81.6 kg (180 lbs)

· Height is 172.7 cm (68 in)

General: Well-appearing.

Eyes: No cotton wool spots, flare hemorrhages, exudates, arteriovenous nicking, or papilledema.

Neck: No thyromegaly, thyroid polyps, or masses. No bruits or jugular venous distension.

Lungs: Clear to auscultation bilaterally in all fields. No crackles, rhonchi, or wheezes.

Heart: Regular rate and rhythm. Regular S1 and S2. No murmurs, thrills, or rubs. Point of maximal impulse is in the left fifth intercostal space (normal).

Abdomen: No surgical scars or deformities. Normal bowel sounds in all quadrants. No bruits. No palpable tenderness or abdominal aortic pulses. No hepatosplenomegaly or other masses.

Extremities: No clubbing, cyanosis, or edema. 2+ pulses bilaterally in upper and lower extremities. Normal capillary refill. No venous stasis changes, erythema, or wounds.

Neurologic Exam: Alert and oriented x 3. Cranial nerves II – XII intact symmetrically. Normal gait and finger to nose testing. Normal proprioception. Reflexes 2+, symmetric bilaterally in upper and lower extremities.

After you leave the exam room, before you go to find Dr. Medel, you calculate Mr. Martin’s body mass index (BMI) using the National Lung, Heart, and Blood Institute BMI calculator, and determine that his BMI of 27 kg/m2 indicates he is overweight.

You are concerned about this since you know that being overweight or obese is a risk factor for hypertension, hypercholesterolemia, diabetes, and many other diseases.

TEACHING POINT

Body Mass Index Categories

· Underweight < 18.5

· Normal weight = 18.5-24.9

· Overweight = 25-29.9

· Obesity = 30-40

· Extreme Obesity > 40

Dr. Medel greets Mr. Martin and proceeds to verify your history and physical.

As Dr. Medel listens, you talk to Mr. Martin about the diagnosis of hypertension. You recommend that he check his blood pressure at home (if he has a cuff) or at the nearest pharmacy a few times per week for the next two weeks, write down the numbers, and bring them to his follow-up visit. You also talk with him about some things that he can do to lower his blood pressure, and you congratulate him for not smoking tobacco.

You ask him to think about how he could increase the amount of activity he gets each week, and you also ask him to think about how he could increase his intake of fresh vegetables and fruits. He thinks, and tells you that he and his wife have been talking about taking more walks together, and that he could try bringing more healthy snacks with him to work. You let him know that these would be great first steps in working to lower his blood pressure. You also share with him the location of a fresh produce market that has bargain prices and a website that offers cost-efficient, healthy meals.

It is two weeks later, and Mr. Martin has returned for his second visit with you.

He tells you that he has been using his wife’s home blood pressure kit to measure his blood pressure several times a week over the past two weeks and all of the readings were between 140-150/80-88 mmHg.

You take his blood pressure and find that it is 156/86 mmHg in his right arm.

You inform Mr. Martin, “The measurements from your last visit and today are all high. Additionally, your readings at home are also elevated. It looks like you do have hypertension.”

TEACHING POINT

White Coat Hypertension

Some people get high blood pressure readings only when they see their doctor, which is why it is important to assess blood pressure outside of the physician’s office. If the home readings are normal, then the patient likely has white coat hypertension. If blood pressure measurements at home remain high, then the patient likely has hypertension. People with white coat hypertension should still receive ongoing surveillance for the development of essential hypertension.

You tell Mr. Martin that you will return to talk to him about next steps, and present your findings to Dr. Medel.

Dr. Medel asks you, “What treatment approaches would you recommend for a patient like Mr. Martin with newly diagnosed Stage 2 hypertension?”

You respond that all patients with newly diagnosed hypertension (or elevated blood pressure) should be counseled about behavioral approaches that they can take to manage their blood pressure. Specifically, the ACC/AHA guidelines recommend weight loss for those who are overweight or obese, a heart healthy diet like the DASH eating plan, sodium restriction, potassium supplementation through dietary measures, increased physical activity, and a limited alcohol intake.

Dr. Medel answers, “Great summary! Would you recommend a medication? If so, which medication? calcium-channel blocker, a thiazide diuretic, an ACE-inhibitor, or an angiotensin-receptor blocker) be started at the time of diagnosis

You suggest to Dr. Medel that you should discuss starting a thiazide diuretic and making further lifestyle modifications with Mr. Martin. She agrees with your recommendations.

You and Dr. Medel discuss the initial testing needed for patients with a new diagnosis of hypertension. Some tests are ordered to help with cardiovascular risk assessment; others to establish a baseline prior to medication use; others to assess for end-organ damage, and others to evaluate for secondary causes of hypertension. A full evaluation for secondary hypertension is only necessary if clinically indicated, but some simple screening tests for identifiable causes should be done upon diagnosis. You order the following:

TEACHING POINT

Initial Testing for New Diagnosis of Hypertension

Lipid profile

Basic Metabolic Panel

Thyroid Stimulating Hormone

Urinalysis

Electrocardiogram

Measurement of urinary albumin excretion or albumin/creatinine ratio

Dr. Medel remarks that your clinical reasoning in this case is excellent. She returns to your discussion of lifestyle modifications and says, “Despite starting a medication or two, lifestyle modifications are still important to discuss because they also reduce blood pressure, enhance antihypertensive medication efficacy, and decrease cardiovascular risks.”

Which lifestyle modification will decrease blood pressure the most?”

 DASH eating plan: Consume a diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of saturated and total fat. 

You and Dr. Medel return to the examination room to see Mr. Martin. Dr. Medel verifies your history and physical examination. You tell Mr. Martin that there is a lot that can be done to treat his blood pressure and to prevent any complications. You discuss the importance of lifestyle modifications and explain the need to do further blood testing and an electrocardiogram.

You check in with Mr. Martin about his goals from the last visit. He reports that he has started taking carrot sticks or apples to work as snacks, and this is working well. He and his wife have also started to take walks together in the evenings, and find that this is an enjoyable time together. They plan to continue and increase the intensity of their walks slowly. You congratulate Mr. Martin on these changes and encourage him to continue.

You also discuss initiating a “water pill” called chlorthalidone that will reduce his blood pressure. After reviewing the risks, benefits, and side effects—including possible increased urination—of chlorthalidone, Mr. Martin agrees to start the medication. He wonders about the need to urinate more often while he is at work, because it is often difficult to find a bathroom while he is driving. You suggest taking the medication in the evening, as this has been shown to be beneficial. You tell him that if this does not work for him, you can try a different medication in the future. You also talk to him about starting a second medication today to more rapidly gain control of his blood pressure.

Mr. Martin also tells you that he is worried about the cost of the medications. You reply, “I can appreciate your concerns about the costs. Chlorthalidone costs about $20 for a month’s supply. We do have social work and pharmacy students here who can help you obtain this medicine free of charge. If this does not work and the cost becomes prohibitive, there is a slightly less expensive version of the medication, hydrochlorathiazide, that we could switch to in the future.” Mr. Martin agrees that he would like to start the chlorthalidone today, but prefers to hold off on a second medication until determining whether his lifestyle modifications and the chlorthalidone are effective.

You give Mr. Martin the orders for his testing, and tell him that you will see him back in four weeks, but to let you know sooner if he has any problems with the medication.

Four weeks later, you are again working with Dr. Medel. You greet Mr. Martin in the waiting area and walk with him to the examination room.

You ask Mr. Martin, “How have you been doing?”

Mr. Martin replies, “I have been feeling well. I have still been checking my blood pressure with my wife’s machine and I think it is getting better. I get a top number in the 130s sometimes. I’ve also tried cutting down on salt—we’ve been trying to use other spices in our cooking at home. The medication is going fine. I think I might urinate a few times more before bed, but then I sleep through the night.”

“That’s great, and your blood pressure does sound better. I’ll check it myself in a moment. Do you have any other concerns, Mr. Martin?”

“No, I think that’s it.”

You take Mr. Martin’s blood pressure. The result is 142/74 mmHg. You tell Mr. Martin that his blood pressure is better than before, which is good news, but that you’d still like the top number to be lower, with a goal of less than 130/80 mmHg.

You review Mr. Martin’s testing from the previous visit. His electrocardiogram shows a normal sinus rhythm, regular rate, and normal axis. There is no evidence of ischemia or left ventricular hypertrophy. His urine does not show any protein or glucose.

His blood work shows:

Blood test

Mr. Martin’s Results

Normal Reference Range

Basic Metabolic Panel

Fasting Glucose

90 mg/dL

70–100 mg/dL

Sodium

140 mmol/L

135–145 mmol/L

Potassium

4.0 mmol/L

3.5–5.0 mmol/L

Chloride

101 mmol/L

95–105 mmol/L

Blood urea nitrogen

19 mg/dL

7–21 mg/dL

Creatinine

0.8 mg/dL

0.8–1.3 mg/dL

eGFR

101 mL/min/1.73m2

90–120 mL/min/1.73m2

Calcium

9.5 mg/dL

8.9–10.1 mg/dL

Lipid Profile

Total cholesterol

189 mg/dL

120–200 mg/dL

Triglycerides

130 mg/dL

70–150 mg/dL

HDL cholesterol

45 mg/dL

45–100 mg/dL

LDL

118 mg/dL

< 100 mg/dL

Thyroid Stimulating Hormone

3.4 mIU/L

0.5–5 mIU/L

You complete a focused physical exam, and step out of the room to review your findings and present them to Dr. Medel.

Question

You recognize that Mr. Martin has several risk factors for atherosclerotic cardiovascular disease (ASCVD) and wonder if he should be started on a statin for lipid management. According to the pooled cohort equations risk calculator, what is Mr. Martin’s estimated 10-year risk of an ASCVD? For reference, Mr. Martin is a 54 year-old male who does not smoke and currently has a systolic blood pressure of 142 mmHg on antihypertensive medication (his lipid profile is above). When asked, he identifies his race/ethnicity as “Latino.” *

< 7.5%

You consider discussing aspirin prophylaxis with Mr. Martin, but first ask Dr. Medel about this option.

TEACHING POINT

When to Initiate Aspirin in Patients with Hypertension

The USPSTF recommends initiating low-dose aspirin use for the primary prevention of cardiovascular disease (CVD) and colorectal cancer (CRC) in adults aged 50 to 59 years who have a 10% or greater 10-year CVD risk, are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years (grade B).

For older patients (ages 60-69) who have a 10% or greater 10-year CVD risk, the decision to initiate low-dose aspirin use for the primary prevention of CVD and CRC should be an individual one. Persons who are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years are more likely to benefit. Persons who place a higher value on the potential benefits than the potential harms may choose to initiate low-dose aspirin (grade C).

There is insufficient evidence to assess the benefits and harms of aspirin prophylaxis in patients younger than 50 and older than 69.

You and Dr. Medel return to the room. You say to Mr. Martin, “First, I appreciate all the hard work that you are doing to bring your blood pressure down, but we still have a little more to go in order to reach our goal. I think you are definitely going in the right direction with the diet changes and walking with your wife. If you need further assistance with your eating plan, our nutrition students are available to support you and answer any questions that may come up.

In terms of medications, it does seem that you’ll need to add a second pill. Would this be OK with you today?”

Mr. Martin tells you that he sees now that he probably needs it, and has become more comfortable with taking medications. You discuss the risks, benefits, side effects, and costs of ACE inhibitors with him, and he is very amenable to your recommendations.

Dr. Medel expresses her concern about his 7.3% 10-year risk of an ASCVD event. She explains, “We can do a lot for you to reduce this risk, and you are doing a lot already. If this risk increases greater than 7.5% we may need to start a cholesterol-lowering drug in the future. For now, let’s work on continuing to control your cholesterol with your diet and exercise. Let’s have you work on it with our nutrition students, and we’ll recheck your cholesterol after six more months of lifestyle changes. Dr. Medel also discusses aspirin prophylaxis with Mr. Martin. He thinks that taking an aspirin is a good idea, but still prefers to start one medication at a time. You agree to discuss it again once his blood pressure is better controlled and his anti-hypertensive regimen is stable.

Dr. Medel writes a prescription for lisinopril 5 mg a day and refills Mr. Martin’s chlorthalidone. You arrange a follow-up appointment in four weeks.

Four weeks later you are back in the student-volunteer free clinic. Carla George, your nursing-student colleague, has taken Mr. Martin’s blood pressure. Carla reports, “Mr. Martin has a blood pressure of 142/74 mmHg today.”

You thank Carla and you greet Mr. Martin. You ask him if he has had any problems with the lisinopril you initiated at the last visit. He states, “Fortunately, I haven’t had any coughing or swelling.”

You take Mr. Martin’s blood pressure again: 140/74 mmHg. You ask if he is taking all of his blood pressure medication, including today’s doses, and if he is still working on his eating plan and exercising. He tells you, “Yes. I am still doing well with everything.”

You find Dr. Medel and share what you have learned. She states, “We have more work to do since Mr. Martin’s blood pressure is still not at goal. Do you think we should refer Mr. Martin to a nephrologist or cardiologist?”

Since Mr. Martin is only on two medications, and is not at the maximum dose of lisinopril, you do not feel that his blood pressure measurement warrants referral to a nephrologist or cardiologist at this point. Additionally, he does not have signs of end-organ damage or evidence of a secondary cause of hypertension, so does not need a major shift in management strategy yet.

You and Dr. Medel go back to see Mr. Martin. Dr. Medel says to Mr. Martin, “I know you are working really hard on your diet and exercise to lower your blood pressure. I want to reiterate that we are here to support you if you need advice. Your blood pressure is better than when you came in but it is still not at goal. Since you have been taking your medications, today we should probably increase your lisinopril from 5 mg once a day to 10 mg once a day.”

After a long pause, Mr. Martin glances off and then back to both of you and says, “I have to admit that I haven’t been taking the lisinopril.”

Dr. Medel replies, “I am so glad you feel comfortable telling us about that.”

“Have you been having problems with this drug?”

Mr. Martin says, “Actually, I never took it.”

“Were you worried about the side effects?”

“Not so much,” Mr. Martin replies, “I just wanted to try reducing the blood pressure myself with my diet and walks and the first medication.”

“What kind of treatment do you think would work?”

Mr. Martin replies, “I was hoping that if I cut down on salt, and increased my walking, that I wouldn’t need any more medication. I don’t want to have a heart attack or stroke, but I am also not a big pill taker.”

“I am glad you shared your concern. I appreciate that taking pills every day is a burden. I think that eating healthier, exercising, and not smoking will definitely help in reducing the amount of pills you take.

“Can I ask what you think causes your high blood pressure?”

“I know it runs in my family, and salty food does not help. But I also think stress makes it worse.”

Dr. Medel explains, “High blood pressure does run in some families and salty food can definitely make things worse. Stress does make your body release hormones that cause your blood pressure to rise, and can sometimes make focusing on taking care of yourself challenging.

“Have you been experiencing a lot of stress lately?”

Mr. Martin replies, “Everything with my family is well, but money is pretty tight these days. Driving a taxi when rising gasoline prices take so much of your money away is tough. It’s on my mind a lot.”

TEACHING POINT

Explanatory Model of Illness and Health and Biomedical Model of Disease

It is important to understand how patients explain the cause of their illness; how they believe it can be managed and treated; and how they think they can stay healthy. The patient’s explanatory model of illness and health may overlap with the clinician’s biomedical model of disease, or may be completely different.

Dr. Medel summarizes Mr. Martin’s concerns about having to take pills and having ongoing financial stressors. She offers Mr. Martin visits with the clinic’s social work students to help him look up potential community, city, state, or federal programs that may help alleviate some of his other financial burdens. She also points out that after she finds the right combinations of individual medications that work for his blood pressure, she can try to consolidate two drugs into one pill whenever possible. Mr. Martin says he is amenable to this plan, and will take both the lisinopril and chlorthalidone for the next month. He’d still like to hold off on starting the aspirin for now.

You schedule a follow-up appointment in one month to check his blood pressure on both medications.

After Mr. Martin leaves, you discuss with Dr. Medel that the patient told you he was taking all his medications, but the story changed after Dr. Medel came in with more questions. Dr. Medel says, “That used to happen to me all the time and still happens sometimes. It can be frustrating, but patients may not feel comfortable bringing things up immediately for many reasons—sometimes they just don’t want to let us down. When it comes to medication adherence, I also try to remember to tell my patients that some of my patients forget their regular medicines sometimes and then ask how often they forget their meds, giving them permission to tell me if they do and normalizing that patients often do.”

“Once we understood Mr. Martin’s concerns, we avoided increasing his medications needlessly. Your excellent communication skills have kept him engaged in his care over the past few months. The worst thing that could have happened is if we continued writing him more prescriptions without listening to him, or for him never to return. You might know everything in a medical textbook, but without excellent listening and communication skills that knowledge may never make a difference for the patient in front of you.”

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