Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in.
A 56-year-old man with a 10-year history of hypertension (HTN) presents for a primary care visit stating he has not taken his high blood pressure medications which include a calcium channel blocker, an angiotensin converting enzyme inhibitor, and thiazide diuretic for the past three months due to, “Running out of the medication and not getting to the pharmacy.”
Today, his blood pressure is 192 over 120 and he is without complaint denying shortness of breath, chest pain, or visual changes. He states, “I just came in today for a visit since I ran out of blood pressure refills. I need to get back to work in a half an hour.” His physical exam shows no acute distress, he has grade 1 hypertensive retinopathy, and an S4 heart sound, his neck veins are within normal limits, chest is clear, no peripheral edema. Resting heart rate is 73. Respiratory rate 16. 12-lead ECG is within normal limits, and his BMI is 33. Which of the following is the next best step in this patient's care?
A. Administer an in-office oral clonidine and re-assess his blood pressure in one hour.
B. Activate EMS with prompt transfer to the emergency department.
C. Restart prior high blood pressure medications with follow-up within the next month.
D. Advise restricting dietary sodium and weight loss to help with BP control.
The correct answer is C. Restart prior blood pressure medications with follow-up within the next month.
Where do you start? First, consider what kind of a question this is. Given that the patient's history includes a significant high blood pressure report with medication nonadherence, we need to consider next steps in his care. This is a plan/intervention question. In a recent podcast, I outlined the clinical condition of hypertensive urgency, where the blood pressure is markedly elevated, but the patient is without signs or symptoms of accelerated hypertensive target organ dysfunction or TOD. And the clinical scenario in hypertensive urgency is clearly what we see in this question. Typically, with hypertensive urgency, it's a patient who has had high blood pressure for a number of years, usually on at least three meds to control high blood pressure, runs out of meds or stopped taking advised meds, and then presents in the clinical setting feeling quite well. And this man is telling you I need to get back to work in a half an hour. But the blood pressure is really elevated.
On physical exam in hypertensive urgency, there are no alarm findings, no hypertensive retinopathy that's high grade—so no grade 3, no grade 4. He has grade 1 hypertensive retinopathy. I'm not one bit surprised by that. But with low-grade hypertensive retinopathy, grade 1/grade 2, there are no visual changes and no permanent finding, doesn't have any black spots in his visual field. He has no shortness of breath, no chest pain, no S3 heart sound, no distended neck veins. All of those findings I just listed are fairly common with hypertensive emergency where there's evidence of hypertensive TOD.
In this scenario, we're being given a normal physical exam with some minor changes. The S4 heart sound, something that's consistent with diastolic dysfunction and common after a number of months of elevated blood pressure. He told us he's been off his meds for three months. A grade 1 hypertensive retinopathy, as I mentioned, low-grade retinopathy, no visual changes, no permanent findings. And in other words, once his blood pressure is treated, both the grade 1 hypertensive retinopathy will go away and as will the S4 heart sound. They'll probably take a number of weeks of decent blood pressure control before those two findings are the physical exam resolve, but resolve they will. So, let's get back to the issue at hand, taking a look at what we see in this clinical scenario:
A 56-year-old man with a 10-year history of hypertension presents for a primary care visit. He states he has not taken his medications, a calcium channel blocker, an angiotensin converting enzyme inhibitor, and a thiazide diuretic for the past three months due to “Running out of the medication and not getting to the pharmacy.” Today's BP is 192 over 120, and he's without complaint denying shortness of breath, chest pain, or visual changes. He states, “I just came in today for a visit since I ran out of high blood pressure refills, and I need to get back to work in a half an hour.” His physical exam shows no acute distress. Grade 1 hypertensive retinopathy and an S4 heart sound. Neck veins within normal limits, chest is clear. No peripheral edema, a resting heart rate of 73, respiratory rate of 16. His 12-lead ECG is within normal limits. BMI is 33. Which of the following is the next best step in this patient's care?
Option B. Activate EMS with prompt transfer to the emergency department. Well, this is also incorrect. Patients with hypertensive urgency do not need to be referred to emergency care or for hospitalization as this is a non-life-threatening situation. All right, so we want to treat him, but he doesn't need to go to the ER.
Would it be C. Restart prior blood pressure medicines with follow-up within the next month? C is the correct answer and the best answer. Patients with hypertensive urgency should be treated by reinstituting their antihypertensive meds, if they've not been taking this for a period of time, and schedule a follow-up visit. If he came in and said, I'm on three high blood pressure medicines, but I'm only taking one of them, what you would do is reinstitute the two he's missing. Or if he came in and he had this scenario, which I doubt, and he was only on one high blood pressure medicine, you would intensify his regimen. But one more time, don't send him to the ER, don't give him something to bring down his blood pressure in-office. Always, always with a patient like this, make sure you schedule a follow-up visit. So, the practice guidelines from the ACC/AHA typically advise that the blood pressure be rechecked in about a month. With a patient like this, I often see them sooner, like I see them back in 1 to 2 weeks. And I'm really not looking for the blood pressure elevation to be resolved. But what I'm looking for is to go over labs, see if they actually got to the pharmacy to pick up the medication, how do they feel on the medication and to really, really reinforce that this patient needs to remain engaged in care and how dangerous untreated high blood pressure is.
Remember, high blood pressure has long been called the silent killer, and that is because it does its dirty work in the background, damaging the brain, the heart, the kidneys, all the blood vessels. And then the person presents with some horrific consequence like a stroke, ACS, chronic kidney disease, whatever. But I will say, of course, part of the plan of care for this patient is investigate as to why the med wasn't refilled. Why did he let his meds run out? Did the patient have difficulty with getting to the pharmacy? Was there a large co-pay that got in the way of picking up the medication? How did the patient feel while on the medication? Or there were intolerable adverse effects that make the patient discontinue the medication? This is as important a part of high blood pressure care as prescribing the correct medication. So, C is our best answer.
D. Advise restricting dietary sodium and encourage weight loss to help with BP control. This is not the best answer, but boy, it's also a correct answer, isn't it? And this is a perfect example of a question that clearly has two correct answers. In real life, you'd be doing both. You would restart his meds and advise about lifestyle changes for better blood pressure control.
His BMI is 33, so he meets that diagnostic criteria of obesity with a BMI of greater than 30. However, C is the better of the two answers, restarting the med. And why is C a better answer? This guy's blood pressure is very high. Will lifestyle modification help with lowering his blood pressure? Because what do we know? Weight loss: the most potent lifestyle modification for BP control. Dietary sodium is like eh, it’s not that great at reducing blood pressure to be perfectly honest with you. What we have is a scenario here with a patient with a markedly elevated blood pressure. The meds are a better choice than the lifestyle modification because the meds will lead him to faster blood pressure control. Would I ever discourage a patient from making wise lifestyle changes? Absolutely not. Would I skip that dialog with this patient? No, no, no, no. I'd have that dialog as well. But C is the better choice. Restart his medication.
Key takeaway: Knowing the difference between hypertensive urgency and hypertensive emergency is key to safe practice. While there is a good deal of overlap between the two conditions, the clinical presentation and the treatment is quite different.
Thank you for listening to NP Certification Q&A presented by Fitzgerald Health Education Associates. Please rate, review, and subscribe to this podcast. And for more NP resources, visit FHEA.com