Tracey: I tell them that we call it a silent killer, and
there's a reason for that.
You don't know you have a problem until it's too late.
. Joe: Welcome to the Evidence-Based Urgentology podcast from EB Medicine,
where urgent care meets evidence.
I'm Joe Toscano, senior research editor for Emergency Medicine Practice,
and a member of the evidence-based Urgent Care editorial board.
Tracey: Hi there, and I'm Tracy Davidoff.
I'm editor in chief of Evidence-Based Urgent Care, and we're practicing
urgent care physicians with years of experience, probably too many years
of experience, on the front lines.
And for us, diagnosis is detective work and the clues are in the history,
the exam, and of course the evidence.
That thrill of solving the patient's puzzle is really
what keeps us coming back.
Joe: Each month we unpack the latest issue of evidence-based urgent care tackling
common chief complaints from presentation.
Through diagnosis to disposition, we highlight the best evidence, the key
takeaways, and the clinical pearls.
Tracey: And by the end of every episode, you'll have sharper skills, deeper
knowledge, and more sound strategies that you can use on your very next shift.
So let's dive in.
The evidence starts now.
And remember, you can always find more at www.ebmedicine.net.
Hi everyone.
Welcome to this episode of the Evidence-Based Urgentology podcast.
Today we're gonna talk about an evidence-based approach to asymptomatic
hypertension in urgent care.
This is something that comes up a whole lot.
A lot of people have it as their MIPS measurements where they have
to, you know, make sure they identify some elevated blood pressure.
And then there's a lot of issues around, should we be treating asymptomatic
hypertension in the urgent care?
Joe: What number's too high?
Tracey: Yeah, what number's too high?
What should we refer to PCPs?
And all those sorts of things.
And there's also been a lot of scariness around numbers.
People are like, oh my God, this is too high.
I have to send them to the ED.
So we're gonna try and sort that out a little bit for you and go
over some of the new recommendations that came out recently.
This issue was written by Melissa Orman, who's the head of operations
for the Orman Physician Coaching group.
She was previously an urgent care physician.
And, a physician educator, which she still is, obviously.
And this was also reviewed by Claude Shackelford who is an assistant professor
of clinical medicine at Vanderbilt.
So, let's get started.
Joe, why don't you start?
Joe: Yeah.
Well, Tracy, the new guidelines seem to focus on tight control,
lifestyle modifications and using symptoms like you alluded to, and
not necessarily the numbers to decide who needs emergent management.
Can you review some of those numbers and flesh some of that stuff out?
Tracey: Oh, absolutely.
So, we always knew recently that, the one 20 over 80 is the, golden spot, but most
people really didn't worry about anything until you got to the one fifties over
the higher than nineties type of thing.
But now they're saying that, the normal cutoff is one 20 over 80 and
if you're 1 21 over 81, you have some degree of abnormal blood pressure.
So, everything in between is of that and 180 over one 20, which we think is like
too high is considered hypertension.
So if you're over one 20, over 80, you have high blood pressure.
180 over 120.
Most people would think, oh my goodness, this is hypertensive urgency, if it
was asymptomatic and hypertensive crisis, if it was symptomatic.
But now the numbers don't really matter.
Well, they do matter.
But as far as deciding whether it's urgency or emergency, the word urgency
is kind of gone by the wayside, and we consider it an emergency if the
patient has high numbers and has some symptoms and signs of end organ damage.
And the very useful acronym for this that I had never heard of before.
But thank you for the authors and probably the research studies that came
up with the acronym bark, B-A-R-K-H.
And this is what you want to think of when you're asking the
patient about end organ damage.
Are they having any symptoms or any signs that refer to damage of
the brain for B. A is arteries.
So that would be like an aortic aneurysm an abdominal aortic aneurysm,
some peripheral vascular disease.
R is for retina.
So is there any visual complaints?
Are they complaining of blurry visions?
Spots, that sort of thing that's new from their previous the K for kidneys.
So we all know, acute renal failure and hypertension and h for the heart.
So are they having chest pain or any signs of cardiac ischemia, congestive
heart failure, that sort of thing.
So, bark, B-A-R-K-H, brain, arteries, retina, kidneys, heart.
So when you're targeting your history and your physical, you wanna make sure
that you're targeting those particular things, even in the person who's just
a little bit elevated and you wanna maybe ask those history and physical
questions to look for that end organ damage to see if there's any of that
going on that you need to worry about.
So anyone who does not have any evidence of acute end organ damage can
safely go home without patient follow up, even if their numbers are high.
So even if that person is that 180 over one 20, if they're totally
asymptomatic and they're there for their sprained ankle and you just
notice that really high blood pressure it's safe to send them home as long as
they have some really good follow up.
You know those people that are maybe lower socioeconomically challenged
or those people who don't have primary care physicians or you're
in an area where it's really hard to get a primary care physician.
We may wanna talk about that a little further and we'll get back to that.
So, Joe, you remember the days of aggressive blood pressure management?
Man I remember dropping a nifedipine capsule with some holes in it
to the patients in the unit when I was a resident way back then.
We don't really recommend any of that acute rapid lowering of
blood pressure based on numbers.
Why not?
Joe: Yeah, no, you're right.
I remember those days too.
Well first off, if there aren't any acute end organ changes, it's not needed and
it doesn't really change any patient centered non number outcomes to do so, to
get it down rapidly in somebody who's not having any symptoms because of it, which
is the vast, vast majority of patients.
But more importantly, there's good evidence that it can be harmful
particularly if it's uncontrolled, like poking that Nifedipine capsule and
squirting it under a patient's tongue.
That was something we did in the ED a lot.
And I can say that back in the early days of urgent care, did it a
time or two, thank God no problems.
But you know, you heard about the problems that were associated with
that just 'cause of the lack of control and people bottoming out.
But you know, even in the ED now where we can titrate an IV agent, we have to do it
gradually and with constant monitoring.
And if it's done too aggressively, it can be harmful.
Tracey: In our clinic we had clonidine and, you know, for people that had
really high numbers, we had the availability of to giving them a
dose of a clonidine to lower their blood pressure sort of semi rapidly.
And we've gotten rid of that now, so we've eliminated all of our rapid,
instant lowering blood pressure medications from our clinic.
So, I urge you to think long and hard about , treating blood pressure
acutely in urgent care if the patient's completely asymptomatic.
Joe: So, the issue cites potential damages to several organs if you bring
the blood pressure down too quickly.
The one we think about the most and we can actually see sometimes is
neuro though and lowering that blood pressure can precipitate stroke.
The brain has its autoregulatory mechanisms that actually adapt
to those increased pressures.
And if all of a sudden that pressure head goes away, the decreased perfusion to the
brain can cause all kinds of bad symptoms.
And really sort of as an example, when patients come in with stroke if they are
not gonna get thrombolytics we let their blood pressure stay all the way up to
two 20 over one 20 in that acute moment.
Now again, that's a long-term risk factor for stroke, but when you're having an
event, we don't even lower it below that.
And even with giving thrombolytics, even with the increased risk
of bleeding, we tolerate blood pressures up as high as 185 over 105.
you know, That acute blood pressure lowing is really not the same
thing as us talking about managing hypertension on a population
basis over longer periods of time.
So we don't need to do it, and it can result in all kinds of problems
bringing it down too quickly . That's the long and the short of it.
You alluded to some lifestyle modifications.
Do urgent care doctors really have time for that?
And if so, how do you handle it?
What do you tell patients when they're in that range where you know they've
got some high blood pressures on the chart, or you talk to them and they
tell you about the high blood pressures they've had over and over again?
Where do you start?
What do you do?
How do you handle it with the limited time you have with them?
Tracey: Yeah, lifestyle modifications, yes, we absolutely a hundred
percent should be doing this.
It just takes a few minutes to mention it, and I found that a lot of people's
primary care doctors don't really mention it to them all that much, unless they're
treating them with medication or, I find that they've been seen over and over again
for like, one 60 over a hundred and the docs mention the lifestyle modifications,
but they don't really follow through with it or give them any, useful
instructions or even treat them sometimes.
They just keep telling them lifestyle modifications and
nothing really happens with that.
So it takes a few minutes to mention it and we all have EMRs that have useful
patient education things in there.
You can print that out for them and recommend that they follow up maybe
with the DASH diet or even, just saying limit salt, do you use that salt shaker?
Get rid of that salt shaker.
Stop eating canned foods.
Stop eating things that are coated in salt.
Maybe ask for those french fries, which you probably shouldn't be eating anyway,
but ask for them without the salt.
Increasing potassium if it's safe to do so.
So if they don't have any renal disorders, maybe add an extra banana a day just
to add some increased potassium that helps support a healthy blood pressure.
Regular exercise.
Many, many of us are terrible at getting regular exercise, but just going for a
walk, you know, half an hour, a couple times a week, it can help lower your
blood pressure by five or 10 points.
Useful to mention weight loss.
I always cringe when I have to tell somebody that, they probably should think
about weight loss because I always feel like I'm, I don't know, I don't wanna
say shaming them, but you know, I'm telling them something without a previous
relationship to them, and anybody who knows me knows that I'm not exactly the
thinnest person in the world either.
So who am I to tell them that they need to lose weight?
But, you know, if you can come up with a nice, gentle way to
mention that, most people know that they're overweight and know that
it would help them to lose weight.
And if you positively reinforce that you're doing some good.
Stress management.
Probably something we don't wanna get too much into in the urgent care scenario,
but just mentioning that stress levels can increase your blood pressure as well.
The other thing I usually like to do, and I actually have one that I can print out
for people, is keep a blood pressure log.
I always tell them, I don't really care what your blood pressure is in
one reading here in the urgent care.
That is not a really good picture of what your blood pressure is in the
normal, everyday world, so take that log.
Get yourself a home blood pressure thing.
Monitor it several times a day.
You first wake up in the morning, maybe after lunch, after work when you're
sitting down watching tv , and the average of your blood pressure is what really
matters in the long term of things.
And if you keep that log, then when you do have that follow up appointment
with your primary care doctor, they can look at that and say, here's what
your trends are and here's what I think we need to do as far as treating it.
Believe me, the primary care doctors will thank you for it.
And then the last thing that I always do, I always talk about the
dangers of untreated hypertension.
I tell them that we call it a silent killer, and there's a reason for that.
You don't know you have a problem until it's too late.
You're walking around with that one 70 over a hundred and not
having any symptoms at all.
So you don't know it's a big deal unless you measure your blood
pressure and see what it is over time.
You won't see anything or feel anything until you have that stroke.
You have that retinal hemorrhage, you know you, find out you're in
stage three B, kidney failure.
And if they're really kind of resistant to that idea when I'm telling them that
I review that risk of stroke, MI, renal failure, and peripheral vascular disease.
And then I say something like, you wanna be there for your grandkids, right?
'cause this is how you manage to get to that point.
You have to make sure that you treat that blood pressure.
You may not feel that it's anything that's necessary because you're asymptomatic,
but it is important, and just think of the strides that we've made over the last
20 years in blood pressure management.
Most people are now partially treated or at least, somewhat lowering their
blood pressure, and we're seeing a lot less of those strokes and those
bleeds and those kidney failures.
So very, very important to talk to people about this sort of stuff.
Even in urgent care, if you can only do one thing, just do one
thing every little bit helps.
So we've decided, hey, it's just a number.
They're asymptomatic.
They don't need to go to the ED.
They can follow up with their PCP even when they're, 1 79 over 119.
We won't say the 180 over 120.
Now what, you know, in urgent care, do we treat them?
Do we do some labs?
Do we do an EKG?
And what do we need to do to make sure that we touch on things other
than the education I mentioned and you know, medications?
What do you think?
Joe: Yeah.
So, I think you really have to take the time to let the patient know that they
have the disease of high blood pressure.
I, think most people know having a high blood pressure means you have the
disease of high blood pressure, whether you wanna call it that or hypertension.
But to just, let people know, Hey, you know what?
Your blood pressure's too high.
It's been high over a, a long enough period of time that
you've come to urgent care here.
That we can say that you have the disease or the condition of high blood pressure.
I love that silent killer thing.
It kind of is a succinct way to tell people of the risk that's
involved, and maybe motivate them to do something about it.
I think a lot of times blood pressure is glossed over in the acute care
setting, and then like you said, even by primary care doctors, the people
who are supposed to be recognizing it and doing something about it.
It's easy just to gloss over because it is silent.
So take the time to inform the patient, Hey, I think this is important, in
addition to your sprained ankle.
Let's talk a little about your blood pressure and what we need
to do from now on about it, and not just note that it's elevated.
Lab work is in general recommended it's screening , to know that there's
no end organ damage with the kidneys.
To be able to get a, little bit of an idea whether you might harm a patient by
giving them certain classes of medicine.
It's helpful.
We don't have access to that and I think there's a way around it probably
and still start some medication.
I'll talk about that in a sec. But at some point they do need to get some labs.
So emphasizing to them that they should see their primary care doctor and do that
even if you make the decision to treat.
You know, In terms of what to use in terms of medications, there's a great chart
in the issue that summarizes the basic classes, and there are four first line
classes of medication, calcium channel blockers, diuretics, ace inhibitors,
and angiotensin receptor blockers.
We're not talking about beta blockers as first line agents.
We're not talking about hydralazine.
You mentioned clonidine and clonidine and alpha agonists are interesting.
Something like tamsulosin that we use as a prostate medication to ease
urination from BPH, that medicine was initially a blood pressure medicine.
And it does lower your blood pressure.
We tell people to be careful with it 'cause it could
lower their blood pressure.
But interestingly, clonidine and those agents don't result in decreased
cardiovascular morbidity and mortality.
They've been tested and one of the reasons why they're really not first
line or in the alpha agonists aren't at all is because even though they
lower your blood pressure, they don't lower your risk of the bad stuff that
high blood pressure causes for some reason, and all these other ones do.
So those are certainly not gonna be anything that you're gonna think about.
Among those calcium channel blocker, diuretic, ACE inhibitor, and ARB, probably
a calcium channel blocker is the easiest one to start without the lab work because
you're not worried if they have renal failure that it's gonna make it worse.
And the potassium isn't gonna be as important as it is with the other agents.
So it might be reasonable to start something like that if
you're at that teachable moment.
It's obvious the patient should be started on something.
They have some follow up, you know, to go ahead and do that.
If you're talking about lab work and if you can get labs basically
a creatinine and a potassium are the most important things to get.
So a basic metabolic panel, a CBC, liver function test, that
kind of stuff doesn't matter.
And there's more complicated labs that are involved if you think the patient
has secondary hypertension, which is really not kind of an urgent care thing.
And because of maybe just starting a single agent.
I think that's maybe where we diverge from the recommendations.
There's somewhat of a complicated recommendation where you use one of the
cardiac risk calculators to determine if the 10 year risk of an event is 7.5% above
that or below that to determine whether you're gonna give the person a little
more time on lifestyle or start something.
But if they're high enough risk and you're making the decision to do that.
The guidelines recommend starting two agents or a single pill with two agents.
And I think that's maybe a little bit too much for us to do on urgent care
where we don't have that continuity relationship, but at least to start them
on something and then, urge the follow up.
That's my approach.
I even do that in the ED, I'm not really starting people on two agents just because
it's a little bit more complicated.
They could have issues with either of them, and it's harder to sort
out when you sort of just kind of discharge them into the void.
Whereas if you're managing them and seeing them in follow up I think it's easier
to start two agents in that situation.
Tracey: Yeah, it was really interesting in the article , it actually mentioned
that for long-term management, you should probably be on three different meds.
On the lowest dose of each, rather than maxing out one and then adding
another, and then maxing out that one and adding another, which is
really, counterintuitive to the way that we used to manage hypertension.
Which I found really interesting.
Joe: Yeah, no, I agree.
I think the end organ changes are the, you know, you talked about
the bark h and almost all of those are related to patient's symptoms.
You don't have to get a blood work or imaging for brain
for retina even, or heart.
You can ask the person, are you having dyspnea or chest pain?
And the issue actually outlines all the questions you should ask.
It's basically a good review of systems.
The one kind of kicker is, is there some kidney disease going on?
And you really need to know the patient's prior creatinine and to call it a
hypertensive urgency based on a creatinine with the patient who feels totally fine.
It's hard to say, I think.
So I think we're okay in urgent care and not necessarily getting
labs, but asking the right questions and doing a physical exam,
you know?
Let's talk about measuring blood pressure.
Tracy.
Anything new that the newest guidelines talk about here?
Tracey: Yeah, I grew up in the emergency room too, and I was an internal medicine
resident and did lots and lots of ICU, we were measuring people's blood
pressures, laying flat, sitting up, sideways, backwards, slapping a cuff
on, not really thinking about how it's done and thinking those were accurate.
But, one of the things that they really mentioned here is, you should make
sure that you're doing it properly and much to my amazement is they're
now saying that automated cuffs are actually better than manual.
The first thing that I would do is, oh, it was a machine.
It's gotta be wrong.
Go take a manual.
And that's actually not true, apparently.
You should make sure, however you know, the patient is really
positioned appropriately.
You wanna have them seated in a chair with both feet on the floor.
You want to give them a few minutes, don't rush 'em in, sit 'em down,
take the blood pressure, and then be surprised when it's elevated.
Wait about five minutes.
Make sure they don't have to pee.
'cause you know,, everybody has high blood pressure if they're
sitting on a full bladder.
Ideally no caffeine and no nicotine before you measure their blood pressure.
Probably not something we're capable of doing in urgent care, but just
something to think about and maybe ask the patient about, and then, make
sure their blood pressure cuff is not through three layers of clothing.
And that it's at the proper level, at the level of the heart, and that
they're relaxed and not talking.
So many times I walk in the room when the patient's being triaged
and I see the medical assistant on the computer, they're asking them
all their past medical history while their blood pressure cuff is cycling.
And you're not gonna get an adequate blood pressure if the person's talking,
because if you think about it, the intrathoracic pressure is going up and
down as you're speaking and breathing.
And that's gonna give you either a false elevated or a falsely low blood pressure.
So quiet, quiet while I take your blood pressure.
And then the other thing that's really important is repeating it.
You get a result that you don't really expect or something that's
on the high side, repeat it again in about five minutes and document it.
, So many times I have the medical assistant will come to me and they'll, like, I took
it three times and this is the lowest one, so that's the one I'm putting in there.
It's probably better to put them all in there to show that you did your due
diligence in repeating the blood pressure.
And then the other thing is considering taking it both arms, it's kind of
rare to see a coarctation or some sort of dissection that would mess
up your blood pressure in either arm.
But some people do have some sort of anatomic variant or maybe they
have some peripheral vascular disease and maybe that arm that
you're taking it is not as accurate.
And maybe you wanna do the other arm and see if there's a difference, because that
might clue you into some other things that you might wanna investigate further, so,
Joe: Then the interesting thing is that you use the higher one.
If you measure it on both arms and ones higher than the higher one is the one
that's a reference standard, and then it's recommended that you continue
to use that arm into the future.
That was actually something, there's that long checklist of things
that you're supposed to do to appropriately measure blood pressure.
And although we don't always do it, you kind of read it and
you go Oh yeah, that's right.
That's right, that's right.
But the thing that was interesting to me is, both arms sometimes,
and then use the higher one rather than averaging or, giving the
patient the lower blood pressure.
Tracey: exactly.
So, um, just wanna mention one special population here.
Pregnancy I guess it does come up a fair amount.
People are pregnant and they come to the urgent care with some other concern,
like they have a cold or a UTI or they sprain their ankle or something like that.
And you really need to look at the vitals in those patients.
What should we be concerned about here with elevated blood pressure in pregnancy.
Joe: Yeah, well , you kind of have to have a sense of whether this pregnant
patient with high blood pressure has pregnancy related high blood
pressure or gestational hypertension, or whether it's a patient who had
hypertension and then became pregnant.
so there really four kind of possible scenarios.
There's somebody with gestational hypertension or there's somebody
with high blood pressure.
Or traditional preexisting hypertension.
And then for either of those patients, they can have that high blood pressure
complicated by pre-eclampsia . So that's the thing that we're kind of
looking for, and the threshold for, the normal blood pressure for a pregnant
patient is that same one 20 over 80.
And when it's below that, they're fine.
When it starts to get elevated, you kind of need to monitor the
patient a little bit more closely.
Value above one 40 over 90 is what gets you the diagnosis
of gestational hypertension.
If it's made, a couple of times, like, I think they actually say two office visits.
Over, four hours apart or something like that.
And then the threshold for severe pre-eclampsia is that one 60 over one
10 that you sometimes see as well.
So these numbers are a little bit different than that one 20
over 80, starting blood pressure medicine if they're one 30 over.
80 you know, if either of those numbers is above that, but that's
the patient who has high blood pressure when they're not pregnant.
So there's, you gotta kind of mix those two things together when you're
making decisions about these patients.
And I have to tell you, this is something, even though I've been practicing for 30
years, I do feel comfortable counseling the patient if their blood pressure's
in that one 20 to one 40 and in 80 to 90 range, and they're feeling well.
But I really would not start a medication for one of these patients
without talking to their OB and making sure that, they know and they agree
that it's the right thing to do.
Due to, side effects of medicines and potential teratogenicity,
there are different medicines that we use for them as well.
So as much comfort as you have with prescribing amlodipine for your ankle
sprain patient with a BP of 180 over a hundred for the fifth time they've
been in urgent care with this or that.
You can't use that in a pregnant patient.
So Labetolol and Nifedipine are the ones that you'll see patients with
gestational hypertension on, and then certainly once they're getting into the
pre-eclampsia range because of their symptoms or blood pressure level and
lab values, kind of need all of those things, then they'll be on, IV meds.
During that.
Time in, in the hospital, not in urgent care.
So yeah, it's worth it to get your hands around that the numbers are a
little bit different and I think the decision making, is different also.
Is this a stable patient, unstable patient?
Do they have pre-eclampsia ? Is it all pregnancy related?
And the issue does a pretty good job talking about that.
Tracey: Yeah, definitely.
I think recognition is the key in that, because it's not the same thresholds,
and one 40 over 95 might be a little bit dangerous in a pregnant person, where we
probably wouldn't even give it much of a second thought in a not pregnant person.
So, definitely have a higher index of suspicion for hypertension
in, the pregnant patients.
Joe: Right.
I think that's what gets us so unraveled about pregnant patients
is you have two patients and one of 'em can't tell you how they feel.
So you gotta kind of guess.
So, let's see if we can wrap up.
what are our take home points here?
Tracey: Well, number one, you know, as I started out with, don't
freak out over the numbers anymore.
It's not a numbers game, it's a symptoms game.
And that's what you really need to worry about.
If somebody comes to you like, oh my God, their blood pressure's one 70 over
a hundred, you ought to do something.
To do something is go ask the patient how they're feeling.
Look for that end organ damage.
Use that bark acronym.
To see if there's anything going on there and then repeat their blood pressure.
It usually goes down in a bit anyway, spontaneously.
The one thing we didn't mention is they were also talking about a lot of people
will attribute hypertension to pain and say, oh, well, they're just in pain.
That's why they have high blood pressure.
The thought is, if you can generate a high blood pressure, even when
you're in pain like that, that it's.
You probably have high blood pressure, not just from the pain.
So don't ever just write that off.
You can always say to the patient, look, your blood pressure's a little high.
Could be a little high 'cause you're in pain.
But, I really think you should probably go follow this up with your
primary care doctor when you're well, just to make sure that there's not a
problem here that we can nip in the, bud early on because really, early
control and tight control is the key.
Just like we're learning with diabetes now.
So definitely something that, that you need to think about.
Joe: Agree.
I think, with the ratcheting down of what's an acceptable blood pressure
to go untreated, and with so many options, really safe options in
terms of medications to treat these patients, I think it's important for
acute care clinicians to pay attention to this and to recognize it, just
like we talked about with pregnant patients, but recognize those numbers
and the thresholds for anybody.
Look back through the chart and see what their blood pressures have been
and put that together with their current blood pressure to help make a
decision, counsel patients appropriately.
And then I think we can feel comfortable starting some of those basic medicines.
If you can get lab work, you can use any one of those that you
feel comfortable prescribing.
If you can't get lab work, maybe a calcium channel blocker, and then, knowing
what follow up the patient has can work in your favor or not and affect your
decision making in a variety of ways.
If they don't have good follow-up, gosh, it might even be more important for
us to take matters into our own hands and just start to treat that patient.
If they do have good follow-up, it's probably easier to kind of kick the can
for some of the decisions, but still maybe not to start the medication, but to
counsel the patient say, look, you need to see your doctor and let them know.
Write down the blood pressures that you have.
Have 'em do a BP log for other ones and to talk to them about, getting the lab work
done and doing the lifestyle measures.
That's important for everybody.
It's basic general health.
But because so many people have trouble instituting those things
to have a, reasonable threshold for starting medication, and you can
always stop it if those lifestyle modifications kick in at some point.
Tracey: Yeah.
Yeah.
One of my take home points is the patient education point.
You gotta tell these people how important this is, and you've gotta
warn them of the consequences of untreated hypertension, and if you
don't have time to sit there for 10 minutes and do it, I understand that.
But you could take a few minutes to just hit the high points.
If you're suturing a laceration or wrapping up an ankle or something, you
can talk about it while you're doing that.
And have some printed matter for people so that they understand.
I mean, A lot of what we give people probably just goes in the garbage anyway,
but, at least make that effort because One of the other things , that I say
all the time is if you want somebody to remember something, say it five times.
So if they hear it five times from.
If they hear it once from me and once from you and once from somebody else.
Eventually when you hit the fifth time, they're gonna start thinking,
Hey, maybe there is something to this blood pressure thing.
Or you can just tell 'em to look on chat gPT No, I'm kidding.
Yeah, I had to argue with a patient today over chat GPT that insisted
that their diagnosis was correct because chat GPT told them so.
Getting more frequent with that.
But yeah, take that time to provide a couple of seconds or a couple of
minutes of patient education because the blood pressure you lower could
be somebody that's important, so
Joe: No, for sure.
You brought up that point of having to tell somebody five times and it's
probably different for different people and it depends on what the message is.
But you know, you hear about people People stopping smoking the 10th time they tried.
If they fail the ninth time, would you just say, yeah, don't worry about it.
It's one of those things we have to keep telling people and, you might
be frustrated when it's documented that the patient's been told four or
five times that they have high blood pressure, but maybe it's that next
time where it's gonna sink in and it's still the right thing to do.
You can't ignore it at that point because the patient is, we have our duty.
Remember the pregnancy number is a little bit different, the decision making a
little bit different for those patients.
Again, we're probably not gonna be starting medication on our own.
Work with their OB, get them back to their OB, be able to recognize blood pressure
values and symptoms that represent that the patient might be getting preeclampsia
and , in that case, you're gonna refer those patients to the ED just like you
would for any hypertensive urgency, basically, or hypertensive emergency.
It's a hypertensive emergency of pregnancy.
Tracey: There you go.
There you go.
And the last take home point.
Measure your blood pressures correctly, make sure they've been measured correctly.
If you're Not happy with what that number is, maybe even go take it yourself.
And make sure that the person was seated with both feet on the floor
not talking, all those things that I just said and document, every time you
take that blood pressure, that's an important key piece of information.
And that should be in the medical record.
Write it down in the EMR.
Do whatever you need to do.
Tell somebody else to do it.
But you know, the more times you document that, the more
times you'll have ammunition to say, Hey, this is hypertension
and it needs to be dealt with.
Back in the day, you know, all the charts were handwritten, it was
really hard to go back and look at people's previous blood pressures.
But now in the EMR you have it in all its glory.
Every previous visit they ever had, you have their blood pressures
all lined up in a row there, right there for you to look at them.
So please look at them, it's important to do that.
Very important to do that.
Joe: Absolutely.
So I heard we have something very interesting next month
Tracey: Oh yes.
MVAs.
Yes.
So excited about that.
Motor vehicle accidents for the urgent care provider.
A lot of interesting things.
I bet you a lot of people are gonna find that they're not doing things
exactly the way they should be.
A lot of few interesting things and a lot of things to get rid of the scary
management of a motor vehicle accident.
I know there are some people out there that are so frightened by that.
They send a lot of people to the emergency room, and then there are a lot of
people that just kind of blow it off, so there's a nice middle ground and we're
gonna, we're gonna talk about that and I'm really hoping that we can actually
get the author to join us on that one.
Like we did last month with the lab testing.
So, very exciting things coming up.
Joe: Mm-hmm.
Can't wait.
Tracey: Yeah.
Thanks everybody for listening.
We appreciate your time and have a great month.
Joe: Yeah.
Take care everyone.
Bye-bye.
Tracey: Bye.
I want to thank everybody to listening to this month's evidence based
urgentology podcast . Just a reminder that subscribers can go to ebmedicine.net
and read the full issue if you want more information, if you haven't already,
Joe: And if you're not a subscriber head to the site.
That's ebmedicine.net to check out what they have.
If you subscribe you'll get access to the article as well as future articles
and the whole archive of all past issues.
Tracey: Look forward to seeing you there.