a young pakistani doctor blogs...
Saturday, December 24, 2005
  Pressure Cooker
Damn it, I’m feeling tense. I’m worried about my result. I’m worried about my step 1 study. I just have a generalized restlessness today. I can’t fathom why this is. I’ve have these problems before, but I’ve coped well enough. When this wretched result comes out, the dust will settle and I’ll probably be able to focus better. I guess I should be stronger that I am, but hey, I worked for this exam for 7 months straight, and had to worry about it from the first day of final year. The score means a lot to me. I just wish I could get a grip. I usually take some propranolol when I get a bit of the jitters. It’s not a habit, but something I do occasionally to help get the day’s work done. So I’m not superman, so what? I once saw this act by Robin Williams where he suggests they should invent a drug called Fuckitol. Having a bad day? Fuckitol! Worried about the result? Fuckitol! Screwed up your Steps? Fuckitol!

I’m also concerned about my mother’s high blood pressure. A couple of weeks ago, she did a whole battery of tests to assess her pulmonary, cardiovascular and renal system. Everything was fine except the echocardiogram, which showed she had mild left ventricular hypertrophy. A previous echo 6-months ago show no signs of such hypertrophy. I started taking her blood pressure twice a day, suspecting hypertrophy secondary to hypertension and was surprised to discover she was walking around with a blood pressure of 180/70 mmHg. I examined the meds she was using for her blood pressure and found they were totally inadequate: 5mg/d of Lisinopril (Zestril) and 80mg/d of Verapamil (Isoptin). I upped the Verapamil to 120mg/d and the Lisinopril to 10mg/d. There was no response over the next two days, so I upped the Lisinopril to 20mg/d and got the blood pressure down to 160/70 mmHg. That was a start so I kept her on the same doses for another couple of days, but today her blood pressure is back to 180/70 mmHg. I’m upping the Lisinopril to 30mg/d from tomorrow and thinking of an increase in the Isoptin as well.

She’s got to stick with the Isoptin (a diuretic would be more effective, I know) because she’s prone to supraventricular tachycardia and the Isoptin takes care of that as well. I want her on the Zestril because she’s also diabetic and ACE-Inhibtors are great for hypertensive diabetics. So if I can get her blood pressure down with these two agents, I’ll be quite happy. I’ve still got some room to work with in terms of increasing the dose and I’m keeping my fingers crossed that a further increase in dosage will do the trick. To complicate matters even more, she’s gots a dry cough which I’m certain is due to the Lisinopril. If it doesn’t go away soon, I’ll have to switch to Lorsartan or another ARB, which I don’t want to do because the ARBs don’t have the same mortality-rate-decreasing profile in diabetics as ACE-Inhibitors.  

Refractory hypertension requiring combined therapy is a little tricky. Fuckitol is not an option here, I’m afraid.  I just hope I’m not treading too gently here in terms of upping the dosage. Maybe I should be more aggressive. Moiz, Aya, Zak, Usman – feel free to comment.  
I think panadol would be the best in this complicated cae of heart-al problem
Has your Mother undergone any lifestyle changes? Any Past history of Hypertension? How many times did you check the BP? Whats her BMI..?
BMI=28. Past Hx of HTN is confirmed for the last 2 years. She's a regular exerciser and now has started to reduce her salt intake. I've been checking her BP twice a day for the past week now.
docs will tell u abt the blood pressure but for ur result tension try this. u did all u could now just believe that God wont let ur hardwork go fruitless.leave it on Him n dont think about it
Rai, your right dude. Absolutely right.
Sir i would suggest three things.
1- Inspite of using two drugs if the control is not good you can always and i think should add a third drug. if my memory serves me right i rad it somewhere that one should not push to the extreme upper limits of two drugs to gain control rather add a third drug. beta blocker may be.
2- ARBs in my opinion would be beneficial. but i do not suggest radical change of class at this point.
3- The thing that troubles me is that the blood pressure did go down but acclimatized to the drug level and came back to this value again. Might be just that she was a little more stressed that day or something. but tell me does she have headaches? Have you got a renal artery scan ever. Hows her kidneys. have they ever been checked. Their function and all you know.
4- is that it is time that you consult a specialist for this case. setting drug dosages is fine but man there is no alternate for experience.
ok i have over shot my quota of points already so i will shut up.
I agree with you Moiz. I'm going to add a thiazide diuretic tomorrow. She's having a tiresome dry cough from the lisinopril so I'm swtiching to ARB. I'm going for a combination thiazide-losartan, of which standard preparations are available.

I've learnt that ARBs have the same long-term effect of decreasing rates of complications like strokes and MIs for diabetics, so I don't mind changing to ARBs. I don't think a change from ACE Inhibitors to ARBs is really a 'class switch'.

Her kidneys are fine, we did a Urine R/E and found everything to be normal. Besides, this wide pulse pressure kind of hypertension (isolated systolic hypertension) is typical of elder people, especially diabetics.

The rebound back up to a systolic BP of 180 worried me too. Maybe the inital drop was a placebo effect? I think also, she might have been tense on the day it rebounded (mother-in-law, daughter-in-law stuff going on in the house!!).

The problem with doctors (and this is a good note to myself!) is that they never really listen to the full history. They look for a few key words, then blast off to the diagnosis without hearing the rest of the story. This happened in front of me when I took my mother to a doctor she really liked. He started prescribing treatment for things that weren't even the chief complaint! I tried to interrupt him a million times to tell him what the problem was, but he just wouldn't listen. Really pissed me off. Besides, with HTN, you've really got to keep checking to see if the medication is having it's effect and adjust accordingly. It's a very hands-on business.

I'll keep trying to bring the BP down myself for another week (it's only been 4 days), and if I fail to do so, I'll take her to a good doctor who had better listen to the full medical history before coming to his brilliant conclusions.

Really...if only doctors actually listened more to their patients instead of going for the most obvious diagnosis and relieving themselves of the hard work of hearing the whole story - I'd trust them more.
I agree with moiz..you need to find a reliable specialist..for long term care..life style changes are in the end the key for long term imrpovement..get your MOther into something like Tai chi..it helps in relaxing and is good for general health
Lifestyle changes are very effective and help the patients a lot but commitment is to be found within the patient.
my mistake no ARB's wouldn't be a 'class switch'.
in any case you are still away from target 20/10. so do use the combination drug.
you are very right doctors don't listen anymore. This springs from many things. one would be the new found confidence in machines for making or reaching a diagnosis for certain. we rely on the machines to make a diagnosis and acept it wothout any question thus we do not think it is worth listening to the actual complaints of the patient.
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Recent med school graduate from Peshawar, Pakistan. Started blogging when in throes of final year exams. Currently studying for USMLE Step 1. Aiming for the 2008 Match. I blog about my studies, my worries, and my thoughts on life. I live in Islamabad.

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