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Man with sky-high BP faces stressful job interview tomorrow

Three GPs discuss a tricky consultation

3

Case history

Mr Stephens has been on treatment for hypertension for about a year. After several attempts his blood pressure is reasonably well controlled on a ?-blocker and diuretic.

He appears in your evening surgery, saying he has been feeling slightly dizzy and would like a blood pressure check as he is being interviewed tomorrow for a top promotion that will involve overseas travel. He tells

you that this is what he has been working

towards for years and that he thrives on stress. His blood pressure is 230/120mmHg.

Dr Melanie Wynne-Jones

'Why has Mr Stephens come today of all days?'

Why is Mr Stephens's blood pressure suddenly so high, and why has he come today of all days? What is the safest course of action, medically, legally and ethically?

I would wonder whether his blood pressure control is as good as it appeared. Some patients are ambivalent about medication, taking it only on check-up days. Perhaps Mr Stephens has side-effects such as impotence or lethargy.

What are the immediate risks? I would ask about symptoms of malignant hypertension, including visual symptoms and headaches, check his fundi, test his urine for protein and send blood for renal function tests. If there were any significant findings, admission might be justified. I would review his records: he may require further investigation.

Today's reading may be due to the stress of his forthcoming interview, but I would ask him to consider that even if he thrives on stress, his blood pressure may be raised for much of the time. His promotion poses several threats to someone with uncontrolled hypertension, including stress of travel and nature of the job. There may be difficulties getting insurance or health care in an emergency. Has he or his family considered this?

He seems worried his hypertension could cost him the job, but his sudden appearance could mean he wants a get-out. A sickness certificate to postpone the interview would be justified if Mr Stephens will accept one; this will buy time for me to control his blood pressure, while he considers his options.

Dr Patrick Wills

'He doesn't have to choose work or health'

The usual rule in diagnosing hypertension is to take several readings over a period of time. However, this level of hypertension may ­ according to British Hypertension Society guidelines ­ require immediate treatment. I would check the blood pressure several times in the consultation, allowing him to relax as much as possible. If the blood pressure remains at this level I would start treatment immediately by adding a calcium antagonist or an a-blocker to his regimen. I would want to avoid possible first-dose effects of an ACE inhibitor, especially if I am in the dark about his renal function.

Malignant hypertension needs to be excluded by examining his fundi and dipping the urine. Secondary causes need to be considered. I would check for radio-femoral delay and pretend I know where and how to listen for renal bruits. I would request renal function tests, cholesterol and glucose.

Despite the guidelines I would still consider his stress and a white-coat element to play a large part in his reading today.

One vital aim is to avoid alienating the patient, scaring him away and raising his blood pressure further. He has an important interview. It is important to emphasise that he doesn't have to choose between his work and his health and he doesn't need a lecture today about weight, diet, salt intake, exercise, alcohol and smoking.

I would want to review him within a week, but I can only do this if I have gained his confidence and communicated the importance of treating this condition.

Dr Peter Harvey

'I would try to persuade him

to postpone his interview '

It's well known that measured blood pressure fluctuates for a variety of reasons ­ the accuracy of the equipment, the competence of the measurer, and the patient's state of arousal. What is the likelihood that today's recording is a true measurement? What previous measurements were 'reasonably well controlled'? Were previous measurements 'normal', or was there a possibility that a high systolic above a silent phase was missed? Is my equipment accurate and am I using a big enough cuff?

Having sat the patient in a quiet room for a few minutes, checked the equipment, and remeasured a BP of 230/120mmHg, it's time to discuss the issue frankly with the patient, who is likely to understand the concept of risk.

If he vouches for his compliance with existing treatment, I would want to add another therapy, trying not to let his commitments deflect me from correct management.

The therapy would include an attempt at fundoscopy,

up-to-date U&Es, and very early reassessment ­ such as the following day ­ for the possibility of malignant hypertension, and thus urgent referral.

I would try to persuade him to postpone his interview, because it is a choice between his health and his career; but there is no reason to suppose the interview cannot be rescheduled ­ it would be if he was physically ill.

However, this is only risk management, and there is a possibility of a catastrophic event, such as a CVA, whatever he chooses.

It just means he is runs a greater risk if he attends the interview tomorrow.

Having excluded white-coat effect with home monitoring, I would hope to engage him in bigger lifestyle choices including taking responsibility for his hypertension, such as monitoring it himself. But I can only make sure he understands those choices.

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