A question of pressure

When Mrs. Jackson came back from Holland after her husband died, she was like a new woman.The stress and strain of taking care of a dying man day and night had taken its toll, but six months vacation in her childhood home had revitalized her. She looked great. Suddenly her blood pressure began to get completely out of whack. She'd been hypertensive during the four or five years I was following her, but it was usually well controlled except for a short period around Angus' death. Now it was up in the sky at stroke provoking levels. I tried to fix it. I reviewed her history, quizzing her for triggers and symptoms. I did a complete physical examination and some blood tests. I played with her anti-hypertensives. It came down only a little. Her blood pressure was scaring her but not making her feel bad. Some of the medications, however, were making her tired. She was having a good time; visiting her children and grandchildren, she was rediscovering her life. The new medications I put her on were putting a hole in that new enjoyment. I am always very careful to take the cost of medication into account when deciding on drug regimen for patients. Her hypertension was not responding to anything cheap. She was on maximal doses of three different drugs, and her pressure was not responding. This was over a hundred dollars a month, a good chunk of her discretionary money—even cutting into her food money. I did not want Mrs. J. to choose between a stroke and breakfast. I called a drug company and convinced them to donate a supply of the most expensive medication. At the same time her blood tests were going out of whack. Her serum potassium was low. This is not an unusual side effect for a patient on diuretics. I putzed around for a few weeks adding potassium supplements. I discussed her case with the nephrologist. He suggested changing her medications. Her pressure stayed high and the side effects got worse. "Here I am with time to enjoy myself and you're making me come here twice a week AND I want to leave and visit my daughter in Nova Scotia." She said. She was peeved. I was frustrated. I was going to send her to see the nephrology consultant. Before I did though, I wanted to look at the case clearly from the beginning. Sometimes this works when I am stuck for a diagnosis. I try to look at the case with fresh eyes. To try and see what I have been blinded to by knowing my patient too well. I sat down and looked through her chart very carefully. I read each note wrote down every blood pressure on a chart with her lab results. Why was her potassium so low? She was on two drugs, which should be making her serum potassium high. Yet she was always so low that I was worried her heart would beat abnormally. What would give you high blood pressure resistant to usual treatment and low potassium? Aha! Asking the question in that way gave me the right answer. Suddenly, it was like I was a cartoon character and the little light bulb over my head went off. She had secondary hypertension. She had an Aldosterone secreting tumour of the adrenals. I called my favourite renal consultant and lay the case before him. "It's possible” he said. "Try her with an aldosterone blocking diuretic if it is true her pressure will fall dramatically." I ordered the drug; it took the pharmacist a few days to get it. It was a medication that is rarely used alone since it is a weak diuretic, but it was old and cheap. One week later Mrs. Jackson pressure was in the normal range. The tortuous sausage link capillaries that I could see looking into her eyes had relaxed into smoothness. In a month all her medications were stopped except that one. Her energy had returned and off she went to her granddaughter's engagement party in Nova Scotia. I had a vivid image of her heart and kidneys breathing a sigh of relief. When she came home, she went off to see the consultant and a CT scan found the tiny benign tumour that had made such a dramatic attempt on my patient's life. We elected not to operate. She was well controlled on the drug. "Just be careful if she ever gets admitted to hospital” said the nephrologist. "Someone is bound to stop the amiloride by mistake." I was happy; I had made a difficult and unusual diagnosis and helped an old and valued patient. Sometimes, you do something good at this job. It is seldom, though that you can make such dramatic and immediate “save.”About a year later, Mrs. Jackson was in the office for a routine visit. Her daughter Carol was with her. This is always a hint. If a patient who usually comes alone shows up with a family member it means something is up. "Tell the doctor," Carol started."Did you know, Dr. Perle that when my mother vacuums, she gets short of breath, gets pain in her stomach and starts sweating." "Now Carol, don't be silly, it’s only my indigestion." replied Mrs. Jackson.Knowing my patient's stoic nature I was not relieved; this sounded like angina to me. I whisked her down to the ER and in no time at all she was admitted. I sent a note to the ER explaining her medication and why she was on them. I put an underline and big letters for her amiloride. I knew it was such an unusual drug people would be tempted to stop it. That is what we always used to do when I was house staff. People would come in on ridiculous and improbable combinations of drugs from three or four different doctors and we would try and stop as many of them as we could.It being late on Friday afternoon, I wanted to get home. I left for the weekend secure in the belief that she was in good hands. On Monday morning I went up to the CCU first thing in the morning. There was a harassed looking medical resident hovering around the bed. "Hello," I said brightly. "I am Mrs. Jackson's family Doctor. How is my patient?" I insisted. "She's supposed to have a cath today but her blood pressure is too high." he replied in a distracted voice. I went over to the nursing station. One of the nurses slipped down Mrs. J's chart and vitals and handed them to me conspiratorially. I looked at the medication list: Amiloride was not there. In fact, there was my letter still sealed in its envelope. I felt terrible, despite my note they had stopped her essential medication. I should have gone upstairs on Friday afternoon. The renal consultant came in on the same errand, to check up on his patient. I handed him the medication list and the blood pressure chart. "Shit," he swore. “This is what I get for not coming up here on Friday." We turned to each other, both feeling guilty. He went over to the resident. "What's happening to my patient?” The resident looked relieved to have one of his own superiors to help him with his problem. "She's supposed to have a cath today but her blood pressure is high in the sky and won't come down no matter what I give.” "Is the patient getting her amiloride?" asked the nephrologist, giving the resident the benefit of the doubt. The resident looked crushed "It seemed like such a stupid drug for someone to be on, I discontinued it.""Didn't you read Dr. Feldman's note?" my usually teddy-bearish consultant was beginning to lose his temper. "She told you not to stop it—just be thankful the patient didn't have a stroke from your mismanagement." I went to see Mrs. Jackson. "I'm so glad to see the two of you!" she said. "I knew things were going wrong but now that you're here I'm sure that everything will be fine." A few days later Mrs. Jackson, was stabilized, cathed and the blockages in her heart were ballooned open. She recovered and went on with her new life.

A question of pressure

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