This post is part of case discussion section for informing and improving the patients management. Today I received a patient with hypertension and was having symptoms like headache.
I tried to discuss the case with various doctors of different departments and hospitals and would like to share my experience and their opinions.
This is a good learning and discussion for such cases, however the information provided here is not for patients directly and they shouldn’t use any medicine mentioned here without discussing with the doctor first as it can lead to serious side effects!
Patient seen in rural area with limited resources specially medicines and lack of in house patient management facilities.
Female patient of almost 45 years of age.
Headache since yesterday evening
History of presenting complains
Patient was alright till yesterday when she went out for routine tasks and came back with extreme headache. Family members complain of weird sentences from her too.
She didn’t eat anything much since then.
Patient is otherwise normal and had no known history of hypertension. However she had a similar episode last year and the doctor probably didn’t diagnose her as hypertensive or any other issue.
Patient was lying comfortably in bed, although bit lethargic.
Blood pressure: 160/90 mm of hg
Temperature: Afebrile – ?
No other relevant complain or examination finding.
The patient is clearly a case of hypertension. So the advise and management was like:
=> Tab Capoten (captopril) 12.5 mg (half 25mg tab) per oral (not sub lingual)
Why wasn’t it given sub lingual, because immediately dropping the blood pressure isn’t recommended until indicated and in my opinion there was no need or indication of bringing down the blood pressure immediately in this patient.
=> Other advise included:
No egg (yolk specially)
Reduced salt intake
Increase water intake
Daily visit to check blood pressure at 12 pm (noon)
Now the advising of antihypertensive medicine was a fun part. We had only capoten (captopril), Atenolol and lasix available that may help in bringing down the blood pressure of this patient. So I decided to discuss it with the seniors.
The message sent by me to them on whatsapp:
Civilian female pt around 45 yrs
No egg, reduce salt, increase water
Tab capoten 12.5mg (1/2 tab of 25mg) per oral x stat
Daily bp monitoring
What medicine should be adviced :
Options: capoten, atenolol (And lasix too available btw)
Whatsapp is an amazing thing, I sent this message to one of our doctors group, one to a cardiology trainee and others generally (these were the ones available). The responses were amazing.
First doctors reply
One of the doctors was amazing! despite clearly stating the options available, he was only available to quote me what’s written in the guideline or book :)
See his reply:
Well it’s quite simple
Abc for under 65 and
Ace, beta blocker and calcium, diuretic
To start someone on ace, u need to have normal renal functions
Well thanks for the advice, but first of all we don’t have the renal functions capability in this area. Why did I share his response here? to give a point that don’t quote books and guidelines only just to give an impression that you have read it :)
Second doctors reply
The response from another one (this got me confused, but I knew there is a flaw in it, so discarded it too):
Well with age more than 45 calcium channel blocker n diuretics r choices… beta blocker has now been taken out n used only with cardiac pts
So diuretic is choice
Lasix 40 mg half a day to start then increase after 10 days plus calcium supplements
As lasix takes away calcium and egg is allowed only yolk restricted with sald and no need to increase water
This seems legitimate, but I’m open to discussion on this response. Please let me know if you have anything related to this or earlier one.
Third doctors reply (cardiologist)
However the response from 2 cardiologists was in favor of atenolol.
First ones conversation:
I would rather start with atenolol 50mg once a day. Capoten isn’t required.
Upon sharing the above mentioned lasix message to this doctor, the response was:
Lasix would never hep solo. We don’t prescribe it as a first line ever. According to the JNC 8 guidelines on HTN.
I asked if atenolol 50mg was safe and wouldn’t lead to hypotension in this patient as we don’t have and probably can’t monitor the patients blood pressure regularly everyday to adjust the dose, the response was:
Lol. Hypotension with just 50mg of atenolol. No way
She is tachycardic as well. so beta blocker would be a good choice
Well this was quite reasonable and explained, and near to my own feeling and understanding of hypertension and drugs used for it, specially among the ones available.
Fourth doctors response (cardiologist)
This doctor replied bit late, maybe they were busy, till then I had followed the third doctor above’s advise. However his opinion was also similar, he said:
Add atenolol 50 mg once a day in addition to capoten half bd
Well I still need to confirm the half capoten twice daily thing here, is it required?
Fifth doctors response (cardiologist)
Fifth doctor replied just now, while I was writing the fourth doctors response just above this one, very late though, but helpful. The doctor said:
Is it reading first only?
Capoten is short acting
Better to give beta blockers if no contraindications
warna ramipace 2.5mg OD is good
Well yes it’s the first reading, and yap capoten is short acting. Better to give beta blockers (given already) and ramipace not available (as mentioned the options available earlier)
I replied that yes itn’s the first reading and we don’t have ramipace available here, and I need to add capoten if using atenolol 50mg od or not? The reply was:
Atenolol 25mg 1BD
Start with one drug, later on if not controlled then add on therapy
I asked if 25mg BD was same as 50mg Once or does it make a huge difference? The response was good:
Dose is BD
Which strength you gave it will work for that 12 hours
So technically 50mg atenolo that I already advised to the patient will work for only 12 hours, need to confirm it from the products manufacturers data.
Google and found info about atenolol on drugs.com and it said that dose is 50mg once daily. It mentioned that the full affect may take up to several weeks to develop and the dose can be increased to 100mg if desired result not achieved with 50mg.
Please discuss anything that should be added to this patients situation for future reference, any criticism and correction is acceptable.
If you have any of your case to be submitted please submit it via comments and if interesting it will be shared via it’s individual post!