1 00:00:00,000 --> 00:00:02,429 Tracey: I tell them that we call it a silent killer, and 2 00:00:02,429 --> 00:00:03,359 there's a reason for that. 3 00:00:03,659 --> 00:00:05,639 You don't know you have a problem until it's too late. 4 00:00:13,101 --> 00:00:16,551 . Joe: Welcome to the Evidence-Based Urgentology podcast from EB Medicine, 5 00:00:16,551 --> 00:00:18,831 where urgent care meets evidence. 6 00:00:18,941 --> 00:00:22,181 I'm Joe Toscano, senior research editor for Emergency Medicine Practice, 7 00:00:22,241 --> 00:00:24,971 and a member of the evidence-based Urgent Care editorial board. 8 00:00:26,276 --> 00:00:27,776 Tracey: Hi there, and I'm Tracy Davidoff. 9 00:00:27,776 --> 00:00:31,046 I'm editor in chief of Evidence-Based Urgent Care, and we're practicing 10 00:00:31,046 --> 00:00:33,926 urgent care physicians with years of experience, probably too many years 11 00:00:33,926 --> 00:00:35,666 of experience, on the front lines. 12 00:00:35,726 --> 00:00:39,596 And for us, diagnosis is detective work and the clues are in the history, 13 00:00:39,596 --> 00:00:41,306 the exam, and of course the evidence. 14 00:00:41,546 --> 00:00:43,706 That thrill of solving the patient's puzzle is really 15 00:00:43,706 --> 00:00:44,846 what keeps us coming back. 16 00:00:45,481 --> 00:00:49,921 Joe: Each month we unpack the latest issue of evidence-based urgent care tackling 17 00:00:49,921 --> 00:00:51,721 common chief complaints from presentation. 18 00:00:51,721 --> 00:00:55,591 Through diagnosis to disposition, we highlight the best evidence, the key 19 00:00:55,591 --> 00:00:56,821 takeaways, and the clinical pearls. 20 00:00:57,691 --> 00:01:00,811 Tracey: And by the end of every episode, you'll have sharper skills, deeper 21 00:01:00,811 --> 00:01:04,531 knowledge, and more sound strategies that you can use on your very next shift. 22 00:01:04,921 --> 00:01:05,881 So let's dive in. 23 00:01:05,881 --> 00:01:07,021 The evidence starts now. 24 00:01:07,171 --> 00:01:12,451 And remember, you can always find more at www.ebmedicine.net. 25 00:01:13,309 --> 00:01:14,119 Hi everyone. 26 00:01:14,119 --> 00:01:18,289 Welcome to this episode of the Evidence-Based Urgentology podcast. 27 00:01:18,559 --> 00:01:23,029 Today we're gonna talk about an evidence-based approach to asymptomatic 28 00:01:23,029 --> 00:01:24,499 hypertension in urgent care. 29 00:01:24,499 --> 00:01:26,149 This is something that comes up a whole lot. 30 00:01:26,619 --> 00:01:29,109 A lot of people have it as their MIPS measurements where they have 31 00:01:29,109 --> 00:01:31,689 to, you know, make sure they identify some elevated blood pressure. 32 00:01:31,779 --> 00:01:36,149 And then there's a lot of issues around, should we be treating asymptomatic 33 00:01:36,149 --> 00:01:37,619 hypertension in the urgent care? 34 00:01:37,983 --> 00:01:38,873 Joe: What number's too high? 35 00:01:38,943 --> 00:01:40,173 Tracey: Yeah, what number's too high? 36 00:01:40,173 --> 00:01:41,852 What should we refer to PCPs? 37 00:01:42,252 --> 00:01:43,386 And all those sorts of things. 38 00:01:43,426 --> 00:01:46,126 And there's also been a lot of scariness around numbers. 39 00:01:46,376 --> 00:01:48,296 People are like, oh my God, this is too high. 40 00:01:48,296 --> 00:01:49,286 I have to send them to the ED. 41 00:01:49,886 --> 00:01:52,606 So we're gonna try and sort that out a little bit for you and go 42 00:01:52,606 --> 00:01:55,176 over some of the new recommendations that came out recently. 43 00:01:55,576 --> 00:01:58,846 This issue was written by Melissa Orman, who's the head of operations 44 00:01:58,846 --> 00:02:00,856 for the Orman Physician Coaching group. 45 00:02:01,256 --> 00:02:03,566 She was previously an urgent care physician. 46 00:02:03,616 --> 00:02:06,306 And, a physician educator, which she still is, obviously. 47 00:02:06,531 --> 00:02:10,581 And this was also reviewed by Claude Shackelford who is an assistant professor 48 00:02:10,581 --> 00:02:11,901 of clinical medicine at Vanderbilt. 49 00:02:12,501 --> 00:02:14,871 So, let's get started. 50 00:02:14,871 --> 00:02:15,891 Joe, why don't you start? 51 00:02:16,241 --> 00:02:16,511 Joe: Yeah. 52 00:02:16,511 --> 00:02:19,721 Well, Tracy, the new guidelines seem to focus on tight control, 53 00:02:19,721 --> 00:02:23,241 lifestyle modifications and using symptoms like you alluded to, and 54 00:02:23,241 --> 00:02:26,871 not necessarily the numbers to decide who needs emergent management. 55 00:02:27,301 --> 00:02:29,961 Can you review some of those numbers and flesh some of that stuff out? 56 00:02:30,031 --> 00:02:30,991 Tracey: Oh, absolutely. 57 00:02:30,991 --> 00:02:36,284 So, we always knew recently that, the one 20 over 80 is the, golden spot, but most 58 00:02:36,284 --> 00:02:40,737 people really didn't worry about anything until you got to the one fifties over 59 00:02:40,737 --> 00:02:43,027 the higher than nineties type of thing. 60 00:02:43,027 --> 00:02:46,657 But now they're saying that, the normal cutoff is one 20 over 80 and 61 00:02:46,657 --> 00:02:51,067 if you're 1 21 over 81, you have some degree of abnormal blood pressure. 62 00:02:51,397 --> 00:02:57,641 So, everything in between is of that and 180 over one 20, which we think is like 63 00:02:57,641 --> 00:02:59,751 too high is considered hypertension. 64 00:02:59,751 --> 00:03:02,691 So if you're over one 20, over 80, you have high blood pressure. 65 00:03:03,383 --> 00:03:04,572 180 over 120. 66 00:03:04,587 --> 00:03:07,827 Most people would think, oh my goodness, this is hypertensive urgency, if it 67 00:03:07,827 --> 00:03:11,697 was asymptomatic and hypertensive crisis, if it was symptomatic. 68 00:03:12,097 --> 00:03:13,747 But now the numbers don't really matter. 69 00:03:13,787 --> 00:03:14,567 Well, they do matter. 70 00:03:14,567 --> 00:03:18,554 But as far as deciding whether it's urgency or emergency, the word urgency 71 00:03:18,554 --> 00:03:22,784 is kind of gone by the wayside, and we consider it an emergency if the 72 00:03:22,784 --> 00:03:28,004 patient has high numbers and has some symptoms and signs of end organ damage. 73 00:03:28,354 --> 00:03:31,684 And the very useful acronym for this that I had never heard of before. 74 00:03:31,684 --> 00:03:35,124 But thank you for the authors and probably the research studies that came 75 00:03:35,124 --> 00:03:38,784 up with the acronym bark, B-A-R-K-H. 76 00:03:38,844 --> 00:03:41,214 And this is what you want to think of when you're asking the 77 00:03:41,214 --> 00:03:42,864 patient about end organ damage. 78 00:03:43,224 --> 00:03:47,224 Are they having any symptoms or any signs that refer to damage of 79 00:03:47,224 --> 00:03:50,314 the brain for B. A is arteries. 80 00:03:50,314 --> 00:03:54,184 So that would be like an aortic aneurysm an abdominal aortic aneurysm, 81 00:03:54,184 --> 00:03:55,864 some peripheral vascular disease. 82 00:03:56,204 --> 00:03:57,434 R is for retina. 83 00:03:57,434 --> 00:03:58,934 So is there any visual complaints? 84 00:03:58,934 --> 00:04:00,224 Are they complaining of blurry visions? 85 00:04:00,574 --> 00:04:04,964 Spots, that sort of thing that's new from their previous the K for kidneys. 86 00:04:04,964 --> 00:04:08,894 So we all know, acute renal failure and hypertension and h for the heart. 87 00:04:08,894 --> 00:04:12,614 So are they having chest pain or any signs of cardiac ischemia, congestive 88 00:04:12,614 --> 00:04:13,994 heart failure, that sort of thing. 89 00:04:14,324 --> 00:04:18,584 So, bark, B-A-R-K-H, brain, arteries, retina, kidneys, heart. 90 00:04:18,944 --> 00:04:22,064 So when you're targeting your history and your physical, you wanna make sure 91 00:04:22,064 --> 00:04:25,914 that you're targeting those particular things, even in the person who's just 92 00:04:25,914 --> 00:04:29,474 a little bit elevated and you wanna maybe ask those history and physical 93 00:04:29,474 --> 00:04:32,971 questions to look for that end organ damage to see if there's any of that 94 00:04:32,971 --> 00:04:34,106 going on that you need to worry about. 95 00:04:34,806 --> 00:04:38,432 So anyone who does not have any evidence of acute end organ damage can 96 00:04:38,432 --> 00:04:42,062 safely go home without patient follow up, even if their numbers are high. 97 00:04:42,062 --> 00:04:46,142 So even if that person is that 180 over one 20, if they're totally 98 00:04:46,142 --> 00:04:48,962 asymptomatic and they're there for their sprained ankle and you just 99 00:04:48,962 --> 00:04:52,942 notice that really high blood pressure it's safe to send them home as long as 100 00:04:52,942 --> 00:04:54,622 they have some really good follow up. 101 00:04:54,962 --> 00:04:59,072 You know those people that are maybe lower socioeconomically challenged 102 00:04:59,102 --> 00:05:01,682 or those people who don't have primary care physicians or you're 103 00:05:01,682 --> 00:05:04,172 in an area where it's really hard to get a primary care physician. 104 00:05:04,502 --> 00:05:07,322 We may wanna talk about that a little further and we'll get back to that. 105 00:05:08,012 --> 00:05:10,982 So, Joe, you remember the days of aggressive blood pressure management? 106 00:05:10,982 --> 00:05:14,642 Man I remember dropping a nifedipine capsule with some holes in it 107 00:05:14,719 --> 00:05:17,709 to the patients in the unit when I was a resident way back then. 108 00:05:17,999 --> 00:05:21,059 We don't really recommend any of that acute rapid lowering of 109 00:05:21,059 --> 00:05:23,129 blood pressure based on numbers. 110 00:05:23,489 --> 00:05:24,029 Why not? 111 00:05:24,729 --> 00:05:25,599 Joe: Yeah, no, you're right. 112 00:05:25,599 --> 00:05:26,709 I remember those days too. 113 00:05:26,959 --> 00:05:30,649 Well first off, if there aren't any acute end organ changes, it's not needed and 114 00:05:30,649 --> 00:05:34,909 it doesn't really change any patient centered non number outcomes to do so, to 115 00:05:34,909 --> 00:05:38,599 get it down rapidly in somebody who's not having any symptoms because of it, which 116 00:05:38,599 --> 00:05:40,669 is the vast, vast majority of patients. 117 00:05:41,119 --> 00:05:43,879 But more importantly, there's good evidence that it can be harmful 118 00:05:43,949 --> 00:05:47,009 particularly if it's uncontrolled, like poking that Nifedipine capsule and 119 00:05:47,009 --> 00:05:48,389 squirting it under a patient's tongue. 120 00:05:48,839 --> 00:05:51,799 That was something we did in the ED a lot. 121 00:05:51,829 --> 00:05:54,439 And I can say that back in the early days of urgent care, did it a 122 00:05:54,439 --> 00:05:56,919 time or two, thank God no problems. 123 00:05:56,919 --> 00:05:59,739 But you know, you heard about the problems that were associated with 124 00:05:59,739 --> 00:06:02,559 that just 'cause of the lack of control and people bottoming out. 125 00:06:02,909 --> 00:06:07,169 But you know, even in the ED now where we can titrate an IV agent, we have to do it 126 00:06:07,169 --> 00:06:09,329 gradually and with constant monitoring. 127 00:06:09,599 --> 00:06:12,119 And if it's done too aggressively, it can be harmful. 128 00:06:12,429 --> 00:06:15,522 Tracey: In our clinic we had clonidine and, you know, for people that had 129 00:06:15,522 --> 00:06:19,152 really high numbers, we had the availability of to giving them a 130 00:06:19,152 --> 00:06:23,662 dose of a clonidine to lower their blood pressure sort of semi rapidly. 131 00:06:23,916 --> 00:06:28,176 And we've gotten rid of that now, so we've eliminated all of our rapid, 132 00:06:28,266 --> 00:06:32,236 instant lowering blood pressure medications from our clinic. 133 00:06:32,236 --> 00:06:35,776 So, I urge you to think long and hard about , treating blood pressure 134 00:06:35,776 --> 00:06:38,386 acutely in urgent care if the patient's completely asymptomatic. 135 00:06:38,966 --> 00:06:42,709 Joe: So, the issue cites potential damages to several organs if you bring 136 00:06:42,709 --> 00:06:44,184 the blood pressure down too quickly. 137 00:06:44,184 --> 00:06:47,093 The one we think about the most and we can actually see sometimes is 138 00:06:47,093 --> 00:06:50,047 neuro though and lowering that blood pressure can precipitate stroke. 139 00:06:50,407 --> 00:06:54,097 The brain has its autoregulatory mechanisms that actually adapt 140 00:06:54,097 --> 00:06:55,477 to those increased pressures. 141 00:06:55,807 --> 00:06:59,287 And if all of a sudden that pressure head goes away, the decreased perfusion to the 142 00:06:59,287 --> 00:07:01,177 brain can cause all kinds of bad symptoms. 143 00:07:01,187 --> 00:07:06,007 And really sort of as an example, when patients come in with stroke if they are 144 00:07:06,007 --> 00:07:09,817 not gonna get thrombolytics we let their blood pressure stay all the way up to 145 00:07:09,817 --> 00:07:11,827 two 20 over one 20 in that acute moment. 146 00:07:12,217 --> 00:07:16,057 Now again, that's a long-term risk factor for stroke, but when you're having an 147 00:07:16,057 --> 00:07:17,937 event, we don't even lower it below that. 148 00:07:17,937 --> 00:07:20,727 And even with giving thrombolytics, even with the increased risk 149 00:07:20,727 --> 00:07:24,757 of bleeding, we tolerate blood pressures up as high as 185 over 105. 150 00:07:24,757 --> 00:07:27,240 you know, That acute blood pressure lowing is really not the same 151 00:07:27,240 --> 00:07:31,520 thing as us talking about managing hypertension on a population 152 00:07:31,520 --> 00:07:33,800 basis over longer periods of time. 153 00:07:33,800 --> 00:07:37,280 So we don't need to do it, and it can result in all kinds of problems 154 00:07:37,280 --> 00:07:39,989 bringing it down too quickly . That's the long and the short of it. 155 00:07:40,689 --> 00:07:43,299 You alluded to some lifestyle modifications. 156 00:07:43,379 --> 00:07:46,139 Do urgent care doctors really have time for that? 157 00:07:46,179 --> 00:07:47,919 And if so, how do you handle it? 158 00:07:47,919 --> 00:07:51,369 What do you tell patients when they're in that range where you know they've 159 00:07:51,369 --> 00:07:54,619 got some high blood pressures on the chart, or you talk to them and they 160 00:07:54,619 --> 00:07:57,059 tell you about the high blood pressures they've had over and over again? 161 00:07:57,279 --> 00:07:57,939 Where do you start? 162 00:07:57,939 --> 00:07:58,569 What do you do? 163 00:07:58,569 --> 00:08:00,759 How do you handle it with the limited time you have with them? 164 00:08:01,039 --> 00:08:03,769 Tracey: Yeah, lifestyle modifications, yes, we absolutely a hundred 165 00:08:03,769 --> 00:08:04,939 percent should be doing this. 166 00:08:05,209 --> 00:08:08,149 It just takes a few minutes to mention it, and I found that a lot of people's 167 00:08:08,149 --> 00:08:11,909 primary care doctors don't really mention it to them all that much, unless they're 168 00:08:11,909 --> 00:08:15,929 treating them with medication or, I find that they've been seen over and over again 169 00:08:15,929 --> 00:08:20,754 for like, one 60 over a hundred and the docs mention the lifestyle modifications, 170 00:08:21,084 --> 00:08:24,124 but they don't really follow through with it or give them any, useful 171 00:08:24,124 --> 00:08:26,744 instructions or even treat them sometimes. 172 00:08:26,744 --> 00:08:28,934 They just keep telling them lifestyle modifications and 173 00:08:28,934 --> 00:08:30,284 nothing really happens with that. 174 00:08:30,624 --> 00:08:34,915 So it takes a few minutes to mention it and we all have EMRs that have useful 175 00:08:34,915 --> 00:08:36,415 patient education things in there. 176 00:08:36,665 --> 00:08:40,285 You can print that out for them and recommend that they follow up maybe 177 00:08:40,285 --> 00:08:44,605 with the DASH diet or even, just saying limit salt, do you use that salt shaker? 178 00:08:44,605 --> 00:08:45,715 Get rid of that salt shaker. 179 00:08:45,715 --> 00:08:46,975 Stop eating canned foods. 180 00:08:47,342 --> 00:08:49,262 Stop eating things that are coated in salt. 181 00:08:49,262 --> 00:08:52,262 Maybe ask for those french fries, which you probably shouldn't be eating anyway, 182 00:08:52,262 --> 00:08:53,582 but ask for them without the salt. 183 00:08:53,922 --> 00:08:56,085 Increasing potassium if it's safe to do so. 184 00:08:56,085 --> 00:08:59,445 So if they don't have any renal disorders, maybe add an extra banana a day just 185 00:08:59,445 --> 00:09:02,835 to add some increased potassium that helps support a healthy blood pressure. 186 00:09:03,265 --> 00:09:04,525 Regular exercise. 187 00:09:04,555 --> 00:09:07,885 Many, many of us are terrible at getting regular exercise, but just going for a 188 00:09:07,885 --> 00:09:11,005 walk, you know, half an hour, a couple times a week, it can help lower your 189 00:09:11,005 --> 00:09:12,775 blood pressure by five or 10 points. 190 00:09:13,175 --> 00:09:14,705 Useful to mention weight loss. 191 00:09:14,705 --> 00:09:18,515 I always cringe when I have to tell somebody that, they probably should think 192 00:09:18,515 --> 00:09:21,785 about weight loss because I always feel like I'm, I don't know, I don't wanna 193 00:09:21,785 --> 00:09:24,859 say shaming them, but you know, I'm telling them something without a previous 194 00:09:24,859 --> 00:09:28,559 relationship to them, and anybody who knows me knows that I'm not exactly the 195 00:09:28,559 --> 00:09:29,759 thinnest person in the world either. 196 00:09:29,759 --> 00:09:31,949 So who am I to tell them that they need to lose weight? 197 00:09:32,339 --> 00:09:34,769 But, you know, if you can come up with a nice, gentle way to 198 00:09:34,769 --> 00:09:37,469 mention that, most people know that they're overweight and know that 199 00:09:37,469 --> 00:09:38,699 it would help them to lose weight. 200 00:09:38,699 --> 00:09:41,219 And if you positively reinforce that you're doing some good. 201 00:09:41,649 --> 00:09:42,669 Stress management. 202 00:09:42,679 --> 00:09:45,791 Probably something we don't wanna get too much into in the urgent care scenario, 203 00:09:45,791 --> 00:09:49,181 but just mentioning that stress levels can increase your blood pressure as well. 204 00:09:49,701 --> 00:09:52,611 The other thing I usually like to do, and I actually have one that I can print out 205 00:09:52,611 --> 00:09:54,291 for people, is keep a blood pressure log. 206 00:09:54,321 --> 00:09:56,811 I always tell them, I don't really care what your blood pressure is in 207 00:09:56,811 --> 00:09:58,251 one reading here in the urgent care. 208 00:09:58,251 --> 00:10:01,611 That is not a really good picture of what your blood pressure is in the 209 00:10:01,611 --> 00:10:04,441 normal, everyday world, so take that log. 210 00:10:04,536 --> 00:10:06,822 Get yourself a home blood pressure thing. 211 00:10:06,822 --> 00:10:08,352 Monitor it several times a day. 212 00:10:08,352 --> 00:10:11,872 You first wake up in the morning, maybe after lunch, after work when you're 213 00:10:11,872 --> 00:10:15,422 sitting down watching tv , and the average of your blood pressure is what really 214 00:10:15,422 --> 00:10:16,832 matters in the long term of things. 215 00:10:16,832 --> 00:10:19,689 And if you keep that log, then when you do have that follow up appointment 216 00:10:19,689 --> 00:10:23,229 with your primary care doctor, they can look at that and say, here's what 217 00:10:23,229 --> 00:10:26,259 your trends are and here's what I think we need to do as far as treating it. 218 00:10:26,619 --> 00:10:28,629 Believe me, the primary care doctors will thank you for it. 219 00:10:29,079 --> 00:10:31,059 And then the last thing that I always do, I always talk about the 220 00:10:31,059 --> 00:10:32,679 dangers of untreated hypertension. 221 00:10:32,709 --> 00:10:36,069 I tell them that we call it a silent killer, and there's a reason for that. 222 00:10:36,369 --> 00:10:38,349 You don't know you have a problem until it's too late. 223 00:10:38,349 --> 00:10:41,163 You're walking around with that one 70 over a hundred and not 224 00:10:41,322 --> 00:10:42,442 having any symptoms at all. 225 00:10:42,442 --> 00:10:44,662 So you don't know it's a big deal unless you measure your blood 226 00:10:44,662 --> 00:10:46,432 pressure and see what it is over time. 227 00:10:46,852 --> 00:10:49,792 You won't see anything or feel anything until you have that stroke. 228 00:10:49,792 --> 00:10:52,652 You have that retinal hemorrhage, you know you, find out you're in 229 00:10:52,712 --> 00:10:54,662 stage three B, kidney failure. 230 00:10:54,992 --> 00:10:58,189 And if they're really kind of resistant to that idea when I'm telling them that 231 00:10:58,189 --> 00:11:01,789 I review that risk of stroke, MI, renal failure, and peripheral vascular disease. 232 00:11:01,789 --> 00:11:04,939 And then I say something like, you wanna be there for your grandkids, right? 233 00:11:05,329 --> 00:11:07,489 'cause this is how you manage to get to that point. 234 00:11:07,489 --> 00:11:09,679 You have to make sure that you treat that blood pressure. 235 00:11:09,899 --> 00:11:13,404 You may not feel that it's anything that's necessary because you're asymptomatic, 236 00:11:13,404 --> 00:11:17,224 but it is important, and just think of the strides that we've made over the last 237 00:11:17,224 --> 00:11:18,874 20 years in blood pressure management. 238 00:11:18,874 --> 00:11:21,814 Most people are now partially treated or at least, somewhat lowering their 239 00:11:21,814 --> 00:11:24,694 blood pressure, and we're seeing a lot less of those strokes and those 240 00:11:24,694 --> 00:11:26,624 bleeds and those kidney failures. 241 00:11:26,624 --> 00:11:29,412 So very, very important to talk to people about this sort of stuff. 242 00:11:29,642 --> 00:11:32,347 Even in urgent care, if you can only do one thing, just do one 243 00:11:32,347 --> 00:11:33,277 thing every little bit helps. 244 00:11:34,359 --> 00:11:36,519 So we've decided, hey, it's just a number. 245 00:11:36,519 --> 00:11:37,479 They're asymptomatic. 246 00:11:37,479 --> 00:11:38,409 They don't need to go to the ED. 247 00:11:39,019 --> 00:11:43,439 They can follow up with their PCP even when they're, 1 79 over 119. 248 00:11:43,459 --> 00:11:44,879 We won't say the 180 over 120. 249 00:11:45,259 --> 00:11:47,659 Now what, you know, in urgent care, do we treat them? 250 00:11:47,659 --> 00:11:48,919 Do we do some labs? 251 00:11:48,919 --> 00:11:49,939 Do we do an EKG? 252 00:11:50,029 --> 00:11:53,239 And what do we need to do to make sure that we touch on things other 253 00:11:53,239 --> 00:11:57,829 than the education I mentioned and you know, medications? 254 00:11:57,829 --> 00:11:58,519 What do you think? 255 00:11:59,219 --> 00:11:59,459 Joe: Yeah. 256 00:11:59,459 --> 00:12:03,352 So, I think you really have to take the time to let the patient know that they 257 00:12:03,352 --> 00:12:05,462 have the disease of high blood pressure. 258 00:12:05,462 --> 00:12:08,552 I, think most people know having a high blood pressure means you have the 259 00:12:08,552 --> 00:12:11,162 disease of high blood pressure, whether you wanna call it that or hypertension. 260 00:12:11,492 --> 00:12:13,142 But to just, let people know, Hey, you know what? 261 00:12:13,142 --> 00:12:14,612 Your blood pressure's too high. 262 00:12:15,032 --> 00:12:17,642 It's been high over a, a long enough period of time that 263 00:12:17,642 --> 00:12:18,842 you've come to urgent care here. 264 00:12:18,842 --> 00:12:22,228 That we can say that you have the disease or the condition of high blood pressure. 265 00:12:22,228 --> 00:12:24,418 I love that silent killer thing. 266 00:12:24,423 --> 00:12:28,150 It kind of is a succinct way to tell people of the risk that's 267 00:12:28,150 --> 00:12:30,570 involved, and maybe motivate them to do something about it. 268 00:12:30,840 --> 00:12:34,740 I think a lot of times blood pressure is glossed over in the acute care 269 00:12:34,740 --> 00:12:37,560 setting, and then like you said, even by primary care doctors, the people 270 00:12:37,560 --> 00:12:41,660 who are supposed to be recognizing it and doing something about it. 271 00:12:41,940 --> 00:12:44,280 It's easy just to gloss over because it is silent. 272 00:12:44,560 --> 00:12:47,830 So take the time to inform the patient, Hey, I think this is important, in 273 00:12:47,830 --> 00:12:49,120 addition to your sprained ankle. 274 00:12:49,310 --> 00:12:51,560 Let's talk a little about your blood pressure and what we need 275 00:12:51,560 --> 00:12:54,950 to do from now on about it, and not just note that it's elevated. 276 00:12:55,340 --> 00:13:00,100 Lab work is in general recommended it's screening , to know that there's 277 00:13:00,100 --> 00:13:01,930 no end organ damage with the kidneys. 278 00:13:02,230 --> 00:13:05,860 To be able to get a, little bit of an idea whether you might harm a patient by 279 00:13:05,860 --> 00:13:07,480 giving them certain classes of medicine. 280 00:13:07,480 --> 00:13:08,200 It's helpful. 281 00:13:08,480 --> 00:13:12,793 We don't have access to that and I think there's a way around it probably 282 00:13:12,793 --> 00:13:14,473 and still start some medication. 283 00:13:14,473 --> 00:13:17,383 I'll talk about that in a sec. But at some point they do need to get some labs. 284 00:13:17,383 --> 00:13:20,510 So emphasizing to them that they should see their primary care doctor and do that 285 00:13:20,510 --> 00:13:22,100 even if you make the decision to treat. 286 00:13:22,630 --> 00:13:26,207 You know, In terms of what to use in terms of medications, there's a great chart 287 00:13:26,387 --> 00:13:31,317 in the issue that summarizes the basic classes, and there are four first line 288 00:13:31,407 --> 00:13:35,713 classes of medication, calcium channel blockers, diuretics, ace inhibitors, 289 00:13:35,713 --> 00:13:38,043 and angiotensin receptor blockers. 290 00:13:38,353 --> 00:13:41,113 We're not talking about beta blockers as first line agents. 291 00:13:41,113 --> 00:13:42,673 We're not talking about hydralazine. 292 00:13:42,893 --> 00:13:47,763 You mentioned clonidine and clonidine and alpha agonists are interesting. 293 00:13:47,813 --> 00:13:51,553 Something like tamsulosin that we use as a prostate medication to ease 294 00:13:51,583 --> 00:13:55,393 urination from BPH, that medicine was initially a blood pressure medicine. 295 00:13:56,093 --> 00:13:57,233 And it does lower your blood pressure. 296 00:13:57,233 --> 00:13:59,153 We tell people to be careful with it 'cause it could 297 00:13:59,153 --> 00:14:00,083 lower their blood pressure. 298 00:14:00,473 --> 00:14:06,910 But interestingly, clonidine and those agents don't result in decreased 299 00:14:06,910 --> 00:14:08,890 cardiovascular morbidity and mortality. 300 00:14:09,160 --> 00:14:12,400 They've been tested and one of the reasons why they're really not first 301 00:14:12,400 --> 00:14:15,790 line or in the alpha agonists aren't at all is because even though they 302 00:14:15,790 --> 00:14:19,630 lower your blood pressure, they don't lower your risk of the bad stuff that 303 00:14:19,630 --> 00:14:22,780 high blood pressure causes for some reason, and all these other ones do. 304 00:14:23,170 --> 00:14:26,530 So those are certainly not gonna be anything that you're gonna think about. 305 00:14:26,890 --> 00:14:31,350 Among those calcium channel blocker, diuretic, ACE inhibitor, and ARB, probably 306 00:14:31,350 --> 00:14:35,340 a calcium channel blocker is the easiest one to start without the lab work because 307 00:14:35,820 --> 00:14:39,060 you're not worried if they have renal failure that it's gonna make it worse. 308 00:14:39,140 --> 00:14:42,740 And the potassium isn't gonna be as important as it is with the other agents. 309 00:14:43,110 --> 00:14:45,510 So it might be reasonable to start something like that if 310 00:14:45,510 --> 00:14:46,950 you're at that teachable moment. 311 00:14:47,400 --> 00:14:49,470 It's obvious the patient should be started on something. 312 00:14:49,470 --> 00:14:51,830 They have some follow up, you know, to go ahead and do that. 313 00:14:52,200 --> 00:14:55,560 If you're talking about lab work and if you can get labs basically 314 00:14:55,560 --> 00:14:58,290 a creatinine and a potassium are the most important things to get. 315 00:14:58,500 --> 00:15:02,010 So a basic metabolic panel, a CBC, liver function test, that 316 00:15:02,010 --> 00:15:03,240 kind of stuff doesn't matter. 317 00:15:03,540 --> 00:15:06,870 And there's more complicated labs that are involved if you think the patient 318 00:15:06,870 --> 00:15:10,380 has secondary hypertension, which is really not kind of an urgent care thing. 319 00:15:10,760 --> 00:15:13,890 And because of maybe just starting a single agent. 320 00:15:14,160 --> 00:15:17,610 I think that's maybe where we diverge from the recommendations. 321 00:15:17,680 --> 00:15:22,390 There's somewhat of a complicated recommendation where you use one of the 322 00:15:22,450 --> 00:15:27,790 cardiac risk calculators to determine if the 10 year risk of an event is 7.5% above 323 00:15:27,790 --> 00:15:31,030 that or below that to determine whether you're gonna give the person a little 324 00:15:31,030 --> 00:15:33,580 more time on lifestyle or start something. 325 00:15:33,910 --> 00:15:37,355 But if they're high enough risk and you're making the decision to do that. 326 00:15:37,805 --> 00:15:42,125 The guidelines recommend starting two agents or a single pill with two agents. 327 00:15:42,275 --> 00:15:44,975 And I think that's maybe a little bit too much for us to do on urgent care 328 00:15:44,975 --> 00:15:48,275 where we don't have that continuity relationship, but at least to start them 329 00:15:48,275 --> 00:15:50,275 on something and then, urge the follow up. 330 00:15:50,275 --> 00:15:51,235 That's my approach. 331 00:15:51,355 --> 00:15:56,080 I even do that in the ED, I'm not really starting people on two agents just because 332 00:15:56,080 --> 00:15:57,820 it's a little bit more complicated. 333 00:15:57,820 --> 00:16:01,090 They could have issues with either of them, and it's harder to sort 334 00:16:01,090 --> 00:16:04,520 out when you sort of just kind of discharge them into the void. 335 00:16:04,850 --> 00:16:08,600 Whereas if you're managing them and seeing them in follow up I think it's easier 336 00:16:08,600 --> 00:16:10,960 to start two agents in that situation. 337 00:16:11,580 --> 00:16:14,064 Tracey: Yeah, it was really interesting in the article , it actually mentioned 338 00:16:14,064 --> 00:16:17,484 that for long-term management, you should probably be on three different meds. 339 00:16:18,184 --> 00:16:22,504 On the lowest dose of each, rather than maxing out one and then adding 340 00:16:22,504 --> 00:16:25,084 another, and then maxing out that one and adding another, which is 341 00:16:25,084 --> 00:16:28,054 really, counterintuitive to the way that we used to manage hypertension. 342 00:16:28,454 --> 00:16:29,534 Which I found really interesting. 343 00:16:30,234 --> 00:16:31,404 Joe: Yeah, no, I agree. 344 00:16:31,704 --> 00:16:35,444 I think the end organ changes are the, you know, you talked about 345 00:16:35,444 --> 00:16:39,374 the bark h and almost all of those are related to patient's symptoms. 346 00:16:39,374 --> 00:16:43,004 You don't have to get a blood work or imaging for brain 347 00:16:43,034 --> 00:16:45,074 for retina even, or heart. 348 00:16:45,504 --> 00:16:47,814 You can ask the person, are you having dyspnea or chest pain? 349 00:16:47,814 --> 00:16:50,544 And the issue actually outlines all the questions you should ask. 350 00:16:50,769 --> 00:16:52,409 It's basically a good review of systems. 351 00:16:52,699 --> 00:16:55,969 The one kind of kicker is, is there some kidney disease going on? 352 00:16:56,329 --> 00:17:00,289 And you really need to know the patient's prior creatinine and to call it a 353 00:17:00,289 --> 00:17:04,609 hypertensive urgency based on a creatinine with the patient who feels totally fine. 354 00:17:04,949 --> 00:17:07,479 It's hard to say, I think. 355 00:17:07,529 --> 00:17:09,689 So I think we're okay in urgent care and not necessarily getting 356 00:17:09,689 --> 00:17:12,119 labs, but asking the right questions and doing a physical exam, 357 00:17:12,119 --> 00:17:12,449 you know? 358 00:17:13,349 --> 00:17:15,029 Let's talk about measuring blood pressure. 359 00:17:15,029 --> 00:17:15,509 Tracy. 360 00:17:15,609 --> 00:17:18,969 Anything new that the newest guidelines talk about here? 361 00:17:19,029 --> 00:17:22,379 Tracey: Yeah, I grew up in the emergency room too, and I was an internal medicine 362 00:17:22,379 --> 00:17:25,319 resident and did lots and lots of ICU, we were measuring people's blood 363 00:17:25,319 --> 00:17:29,089 pressures, laying flat, sitting up, sideways, backwards, slapping a cuff 364 00:17:29,089 --> 00:17:32,119 on, not really thinking about how it's done and thinking those were accurate. 365 00:17:32,119 --> 00:17:35,639 But, one of the things that they really mentioned here is, you should make 366 00:17:35,639 --> 00:17:39,573 sure that you're doing it properly and much to my amazement is they're 367 00:17:39,573 --> 00:17:42,580 now saying that automated cuffs are actually better than manual. 368 00:17:42,860 --> 00:17:45,020 The first thing that I would do is, oh, it was a machine. 369 00:17:45,020 --> 00:17:45,770 It's gotta be wrong. 370 00:17:45,770 --> 00:17:46,610 Go take a manual. 371 00:17:46,800 --> 00:17:49,290 And that's actually not true, apparently. 372 00:17:49,590 --> 00:17:52,537 You should make sure, however you know, the patient is really 373 00:17:52,537 --> 00:17:53,617 positioned appropriately. 374 00:17:53,617 --> 00:17:56,437 You wanna have them seated in a chair with both feet on the floor. 375 00:17:56,687 --> 00:17:59,447 You want to give them a few minutes, don't rush 'em in, sit 'em down, 376 00:17:59,447 --> 00:18:01,997 take the blood pressure, and then be surprised when it's elevated. 377 00:18:02,422 --> 00:18:03,652 Wait about five minutes. 378 00:18:03,772 --> 00:18:05,032 Make sure they don't have to pee. 379 00:18:05,512 --> 00:18:07,545 'cause you know,, everybody has high blood pressure if they're 380 00:18:07,545 --> 00:18:08,535 sitting on a full bladder. 381 00:18:08,945 --> 00:18:12,369 Ideally no caffeine and no nicotine before you measure their blood pressure. 382 00:18:12,369 --> 00:18:15,309 Probably not something we're capable of doing in urgent care, but just 383 00:18:15,309 --> 00:18:19,699 something to think about and maybe ask the patient about, and then, make 384 00:18:19,699 --> 00:18:22,909 sure their blood pressure cuff is not through three layers of clothing. 385 00:18:23,159 --> 00:18:26,579 And that it's at the proper level, at the level of the heart, and that 386 00:18:26,579 --> 00:18:28,109 they're relaxed and not talking. 387 00:18:28,329 --> 00:18:31,059 So many times I walk in the room when the patient's being triaged 388 00:18:31,059 --> 00:18:34,209 and I see the medical assistant on the computer, they're asking them 389 00:18:34,209 --> 00:18:36,849 all their past medical history while their blood pressure cuff is cycling. 390 00:18:37,129 --> 00:18:40,219 And you're not gonna get an adequate blood pressure if the person's talking, 391 00:18:40,219 --> 00:18:43,239 because if you think about it, the intrathoracic pressure is going up and 392 00:18:43,239 --> 00:18:44,919 down as you're speaking and breathing. 393 00:18:45,229 --> 00:18:49,979 And that's gonna give you either a false elevated or a falsely low blood pressure. 394 00:18:50,259 --> 00:18:52,389 So quiet, quiet while I take your blood pressure. 395 00:18:52,689 --> 00:18:54,909 And then the other thing that's really important is repeating it. 396 00:18:54,909 --> 00:18:57,880 You get a result that you don't really expect or something that's 397 00:18:57,880 --> 00:19:01,400 on the high side, repeat it again in about five minutes and document it. 398 00:19:01,440 --> 00:19:04,950 , So many times I have the medical assistant will come to me and they'll, like, I took 399 00:19:04,950 --> 00:19:08,280 it three times and this is the lowest one, so that's the one I'm putting in there. 400 00:19:08,560 --> 00:19:11,380 It's probably better to put them all in there to show that you did your due 401 00:19:11,380 --> 00:19:13,240 diligence in repeating the blood pressure. 402 00:19:13,600 --> 00:19:16,450 And then the other thing is considering taking it both arms, it's kind of 403 00:19:16,450 --> 00:19:20,207 rare to see a coarctation or some sort of dissection that would mess 404 00:19:20,207 --> 00:19:21,587 up your blood pressure in either arm. 405 00:19:21,957 --> 00:19:25,497 But some people do have some sort of anatomic variant or maybe they 406 00:19:25,497 --> 00:19:28,287 have some peripheral vascular disease and maybe that arm that 407 00:19:28,287 --> 00:19:29,877 you're taking it is not as accurate. 408 00:19:29,877 --> 00:19:32,997 And maybe you wanna do the other arm and see if there's a difference, because that 409 00:19:32,997 --> 00:19:37,177 might clue you into some other things that you might wanna investigate further, so, 410 00:19:37,437 --> 00:19:39,897 Joe: Then the interesting thing is that you use the higher one. 411 00:19:40,227 --> 00:19:43,847 If you measure it on both arms and ones higher than the higher one is the one 412 00:19:43,847 --> 00:19:46,772 that's a reference standard, and then it's recommended that you continue 413 00:19:47,152 --> 00:19:48,742 to use that arm into the future. 414 00:19:48,742 --> 00:19:51,432 That was actually something, there's that long checklist of things 415 00:19:51,432 --> 00:19:54,342 that you're supposed to do to appropriately measure blood pressure. 416 00:19:54,342 --> 00:19:56,182 And although we don't always do it, you kind of read it and 417 00:19:56,182 --> 00:19:57,022 you go Oh yeah, that's right. 418 00:19:57,042 --> 00:19:57,852 That's right, that's right. 419 00:19:57,852 --> 00:20:01,122 But the thing that was interesting to me is, both arms sometimes, 420 00:20:01,122 --> 00:20:03,992 and then use the higher one rather than averaging or, giving the 421 00:20:03,992 --> 00:20:06,145 patient the lower blood pressure. 422 00:20:06,995 --> 00:20:07,655 Tracey: exactly. 423 00:20:08,135 --> 00:20:11,542 So, um, just wanna mention one special population here. 424 00:20:11,542 --> 00:20:13,972 Pregnancy I guess it does come up a fair amount. 425 00:20:13,972 --> 00:20:16,912 People are pregnant and they come to the urgent care with some other concern, 426 00:20:16,912 --> 00:20:20,182 like they have a cold or a UTI or they sprain their ankle or something like that. 427 00:20:20,582 --> 00:20:22,652 And you really need to look at the vitals in those patients. 428 00:20:22,652 --> 00:20:25,585 What should we be concerned about here with elevated blood pressure in pregnancy. 429 00:20:26,285 --> 00:20:29,835 Joe: Yeah, well , you kind of have to have a sense of whether this pregnant 430 00:20:29,835 --> 00:20:33,045 patient with high blood pressure has pregnancy related high blood 431 00:20:33,045 --> 00:20:37,215 pressure or gestational hypertension, or whether it's a patient who had 432 00:20:37,215 --> 00:20:39,165 hypertension and then became pregnant. 433 00:20:39,865 --> 00:20:42,805 so there really four kind of possible scenarios. 434 00:20:42,805 --> 00:20:45,985 There's somebody with gestational hypertension or there's somebody 435 00:20:45,985 --> 00:20:46,795 with high blood pressure. 436 00:20:47,300 --> 00:20:49,400 Or traditional preexisting hypertension. 437 00:20:49,550 --> 00:20:54,150 And then for either of those patients, they can have that high blood pressure 438 00:20:54,150 --> 00:20:57,754 complicated by pre-eclampsia . So that's the thing that we're kind of 439 00:20:57,754 --> 00:21:02,434 looking for, and the threshold for, the normal blood pressure for a pregnant 440 00:21:02,434 --> 00:21:04,474 patient is that same one 20 over 80. 441 00:21:04,574 --> 00:21:05,984 And when it's below that, they're fine. 442 00:21:06,374 --> 00:21:09,164 When it starts to get elevated, you kind of need to monitor the 443 00:21:09,164 --> 00:21:10,784 patient a little bit more closely. 444 00:21:11,124 --> 00:21:14,394 Value above one 40 over 90 is what gets you the diagnosis 445 00:21:14,394 --> 00:21:15,624 of gestational hypertension. 446 00:21:15,624 --> 00:21:19,864 If it's made, a couple of times, like, I think they actually say two office visits. 447 00:21:20,224 --> 00:21:22,444 Over, four hours apart or something like that. 448 00:21:22,774 --> 00:21:27,508 And then the threshold for severe pre-eclampsia is that one 60 over one 449 00:21:27,508 --> 00:21:29,558 10 that you sometimes see as well. 450 00:21:29,708 --> 00:21:32,408 So these numbers are a little bit different than that one 20 451 00:21:32,408 --> 00:21:36,368 over 80, starting blood pressure medicine if they're one 30 over. 452 00:21:36,583 --> 00:21:40,303 80 you know, if either of those numbers is above that, but that's 453 00:21:40,303 --> 00:21:42,943 the patient who has high blood pressure when they're not pregnant. 454 00:21:42,943 --> 00:21:45,703 So there's, you gotta kind of mix those two things together when you're 455 00:21:45,703 --> 00:21:47,903 making decisions about these patients. 456 00:21:47,903 --> 00:21:51,053 And I have to tell you, this is something, even though I've been practicing for 30 457 00:21:51,053 --> 00:21:55,063 years, I do feel comfortable counseling the patient if their blood pressure's 458 00:21:55,433 --> 00:21:59,603 in that one 20 to one 40 and in 80 to 90 range, and they're feeling well. 459 00:21:59,853 --> 00:22:03,003 But I really would not start a medication for one of these patients 460 00:22:03,003 --> 00:22:06,783 without talking to their OB and making sure that, they know and they agree 461 00:22:06,783 --> 00:22:08,043 that it's the right thing to do. 462 00:22:08,403 --> 00:22:12,363 Due to, side effects of medicines and potential teratogenicity, 463 00:22:12,573 --> 00:22:14,593 there are different medicines that we use for them as well. 464 00:22:14,843 --> 00:22:19,093 So as much comfort as you have with prescribing amlodipine for your ankle 465 00:22:19,093 --> 00:22:22,973 sprain patient with a BP of 180 over a hundred for the fifth time they've 466 00:22:22,973 --> 00:22:24,773 been in urgent care with this or that. 467 00:22:25,083 --> 00:22:26,823 You can't use that in a pregnant patient. 468 00:22:26,823 --> 00:22:30,633 So Labetolol and Nifedipine are the ones that you'll see patients with 469 00:22:30,633 --> 00:22:34,207 gestational hypertension on, and then certainly once they're getting into the 470 00:22:34,207 --> 00:22:38,532 pre-eclampsia range because of their symptoms or blood pressure level and 471 00:22:38,532 --> 00:22:42,692 lab values, kind of need all of those things, then they'll be on, IV meds. 472 00:22:42,772 --> 00:22:43,252 During that. 473 00:22:43,322 --> 00:22:45,602 Time in, in the hospital, not in urgent care. 474 00:22:46,022 --> 00:22:48,692 So yeah, it's worth it to get your hands around that the numbers are a 475 00:22:48,692 --> 00:22:52,122 little bit different and I think the decision making, is different also. 476 00:22:52,172 --> 00:22:53,942 Is this a stable patient, unstable patient? 477 00:22:53,942 --> 00:22:56,737 Do they have pre-eclampsia ? Is it all pregnancy related? 478 00:22:57,437 --> 00:22:59,780 And the issue does a pretty good job talking about that. 479 00:23:00,010 --> 00:23:00,550 Tracey: Yeah, definitely. 480 00:23:00,550 --> 00:23:03,730 I think recognition is the key in that, because it's not the same thresholds, 481 00:23:03,780 --> 00:23:08,925 and one 40 over 95 might be a little bit dangerous in a pregnant person, where we 482 00:23:08,925 --> 00:23:11,805 probably wouldn't even give it much of a second thought in a not pregnant person. 483 00:23:12,235 --> 00:23:15,735 So, definitely have a higher index of suspicion for hypertension 484 00:23:15,735 --> 00:23:16,888 in, the pregnant patients. 485 00:23:17,588 --> 00:23:17,938 Joe: Right. 486 00:23:18,068 --> 00:23:21,663 I think that's what gets us so unraveled about pregnant patients 487 00:23:21,663 --> 00:23:24,933 is you have two patients and one of 'em can't tell you how they feel. 488 00:23:25,213 --> 00:23:26,503 So you gotta kind of guess. 489 00:23:27,203 --> 00:23:28,683 So, let's see if we can wrap up. 490 00:23:28,683 --> 00:23:30,003 what are our take home points here? 491 00:23:30,453 --> 00:23:32,643 Tracey: Well, number one, you know, as I started out with, don't 492 00:23:32,643 --> 00:23:34,083 freak out over the numbers anymore. 493 00:23:34,133 --> 00:23:36,203 It's not a numbers game, it's a symptoms game. 494 00:23:36,543 --> 00:23:38,283 And that's what you really need to worry about. 495 00:23:38,283 --> 00:23:41,913 If somebody comes to you like, oh my God, their blood pressure's one 70 over 496 00:23:41,913 --> 00:23:43,503 a hundred, you ought to do something. 497 00:23:43,833 --> 00:23:45,993 To do something is go ask the patient how they're feeling. 498 00:23:46,273 --> 00:23:47,743 Look for that end organ damage. 499 00:23:47,743 --> 00:23:49,093 Use that bark acronym. 500 00:23:49,388 --> 00:23:52,658 To see if there's anything going on there and then repeat their blood pressure. 501 00:23:52,658 --> 00:23:55,118 It usually goes down in a bit anyway, spontaneously. 502 00:23:55,428 --> 00:23:58,728 The one thing we didn't mention is they were also talking about a lot of people 503 00:23:58,728 --> 00:24:01,788 will attribute hypertension to pain and say, oh, well, they're just in pain. 504 00:24:01,788 --> 00:24:03,078 That's why they have high blood pressure. 505 00:24:03,418 --> 00:24:06,268 The thought is, if you can generate a high blood pressure, even when 506 00:24:06,268 --> 00:24:07,588 you're in pain like that, that it's. 507 00:24:07,948 --> 00:24:11,158 You probably have high blood pressure, not just from the pain. 508 00:24:11,158 --> 00:24:12,658 So don't ever just write that off. 509 00:24:12,688 --> 00:24:15,298 You can always say to the patient, look, your blood pressure's a little high. 510 00:24:15,778 --> 00:24:17,428 Could be a little high 'cause you're in pain. 511 00:24:17,428 --> 00:24:19,738 But, I really think you should probably go follow this up with your 512 00:24:19,738 --> 00:24:23,138 primary care doctor when you're well, just to make sure that there's not a 513 00:24:23,138 --> 00:24:26,568 problem here that we can nip in the, bud early on because really, early 514 00:24:26,568 --> 00:24:28,478 control and tight control is the key. 515 00:24:28,478 --> 00:24:30,248 Just like we're learning with diabetes now. 516 00:24:30,248 --> 00:24:33,188 So definitely something that, that you need to think about. 517 00:24:33,615 --> 00:24:34,095 Joe: Agree. 518 00:24:34,795 --> 00:24:39,945 I think, with the ratcheting down of what's an acceptable blood pressure 519 00:24:39,945 --> 00:24:44,552 to go untreated, and with so many options, really safe options in 520 00:24:44,552 --> 00:24:47,562 terms of medications to treat these patients, I think it's important for 521 00:24:47,612 --> 00:24:52,137 acute care clinicians to pay attention to this and to recognize it, just 522 00:24:52,137 --> 00:24:54,987 like we talked about with pregnant patients, but recognize those numbers 523 00:24:54,987 --> 00:24:56,577 and the thresholds for anybody. 524 00:24:56,967 --> 00:24:59,847 Look back through the chart and see what their blood pressures have been 525 00:24:59,847 --> 00:25:02,097 and put that together with their current blood pressure to help make a 526 00:25:02,097 --> 00:25:04,377 decision, counsel patients appropriately. 527 00:25:04,587 --> 00:25:08,547 And then I think we can feel comfortable starting some of those basic medicines. 528 00:25:08,767 --> 00:25:11,017 If you can get lab work, you can use any one of those that you 529 00:25:11,017 --> 00:25:12,097 feel comfortable prescribing. 530 00:25:12,347 --> 00:25:16,317 If you can't get lab work, maybe a calcium channel blocker, and then, knowing 531 00:25:16,317 --> 00:25:20,797 what follow up the patient has can work in your favor or not and affect your 532 00:25:20,797 --> 00:25:22,477 decision making in a variety of ways. 533 00:25:22,827 --> 00:25:26,487 If they don't have good follow-up, gosh, it might even be more important for 534 00:25:26,487 --> 00:25:30,357 us to take matters into our own hands and just start to treat that patient. 535 00:25:30,757 --> 00:25:34,897 If they do have good follow-up, it's probably easier to kind of kick the can 536 00:25:34,897 --> 00:25:38,317 for some of the decisions, but still maybe not to start the medication, but to 537 00:25:38,317 --> 00:25:41,887 counsel the patient say, look, you need to see your doctor and let them know. 538 00:25:42,107 --> 00:25:44,057 Write down the blood pressures that you have. 539 00:25:44,117 --> 00:25:48,777 Have 'em do a BP log for other ones and to talk to them about, getting the lab work 540 00:25:48,777 --> 00:25:50,243 done and doing the lifestyle measures. 541 00:25:50,253 --> 00:25:51,333 That's important for everybody. 542 00:25:51,333 --> 00:25:52,773 It's basic general health. 543 00:25:53,223 --> 00:25:56,223 But because so many people have trouble instituting those things 544 00:25:56,623 --> 00:25:59,323 to have a, reasonable threshold for starting medication, and you can 545 00:25:59,323 --> 00:26:02,893 always stop it if those lifestyle modifications kick in at some point. 546 00:26:03,063 --> 00:26:03,423 Tracey: Yeah. 547 00:26:03,933 --> 00:26:04,203 Yeah. 548 00:26:04,213 --> 00:26:06,763 One of my take home points is the patient education point. 549 00:26:06,763 --> 00:26:09,823 You gotta tell these people how important this is, and you've gotta 550 00:26:09,823 --> 00:26:13,043 warn them of the consequences of untreated hypertension, and if you 551 00:26:13,043 --> 00:26:15,863 don't have time to sit there for 10 minutes and do it, I understand that. 552 00:26:15,863 --> 00:26:18,443 But you could take a few minutes to just hit the high points. 553 00:26:18,443 --> 00:26:21,143 If you're suturing a laceration or wrapping up an ankle or something, you 554 00:26:21,143 --> 00:26:22,763 can talk about it while you're doing that. 555 00:26:23,143 --> 00:26:26,263 And have some printed matter for people so that they understand. 556 00:26:26,263 --> 00:26:29,323 I mean, A lot of what we give people probably just goes in the garbage anyway, 557 00:26:29,323 --> 00:26:33,423 but, at least make that effort because One of the other things , that I say 558 00:26:33,423 --> 00:26:35,943 all the time is if you want somebody to remember something, say it five times. 559 00:26:36,193 --> 00:26:38,173 So if they hear it five times from. 560 00:26:38,353 --> 00:26:41,398 If they hear it once from me and once from you and once from somebody else. 561 00:26:41,608 --> 00:26:44,128 Eventually when you hit the fifth time, they're gonna start thinking, 562 00:26:44,128 --> 00:26:46,458 Hey, maybe there is something to this blood pressure thing. 563 00:26:47,158 --> 00:26:49,648 Or you can just tell 'em to look on chat gPT No, I'm kidding. 564 00:26:49,968 --> 00:26:53,448 Yeah, I had to argue with a patient today over chat GPT that insisted 565 00:26:53,448 --> 00:26:56,658 that their diagnosis was correct because chat GPT told them so. 566 00:26:57,058 --> 00:26:58,108 Getting more frequent with that. 567 00:26:58,108 --> 00:27:02,068 But yeah, take that time to provide a couple of seconds or a couple of 568 00:27:02,068 --> 00:27:05,350 minutes of patient education because the blood pressure you lower could 569 00:27:05,350 --> 00:27:07,615 be somebody that's important, so 570 00:27:08,315 --> 00:27:08,855 Joe: No, for sure. 571 00:27:08,865 --> 00:27:12,465 You brought up that point of having to tell somebody five times and it's 572 00:27:12,465 --> 00:27:15,135 probably different for different people and it depends on what the message is. 573 00:27:15,475 --> 00:27:20,517 But you know, you hear about people People stopping smoking the 10th time they tried. 574 00:27:20,943 --> 00:27:24,243 If they fail the ninth time, would you just say, yeah, don't worry about it. 575 00:27:24,573 --> 00:27:27,493 It's one of those things we have to keep telling people and, you might 576 00:27:27,493 --> 00:27:31,783 be frustrated when it's documented that the patient's been told four or 577 00:27:31,783 --> 00:27:34,543 five times that they have high blood pressure, but maybe it's that next 578 00:27:34,543 --> 00:27:37,333 time where it's gonna sink in and it's still the right thing to do. 579 00:27:37,333 --> 00:27:41,588 You can't ignore it at that point because the patient is, we have our duty. 580 00:27:42,028 --> 00:27:45,058 Remember the pregnancy number is a little bit different, the decision making a 581 00:27:45,058 --> 00:27:46,318 little bit different for those patients. 582 00:27:46,318 --> 00:27:49,408 Again, we're probably not gonna be starting medication on our own. 583 00:27:49,658 --> 00:27:54,603 Work with their OB, get them back to their OB, be able to recognize blood pressure 584 00:27:54,603 --> 00:27:58,113 values and symptoms that represent that the patient might be getting preeclampsia 585 00:27:58,443 --> 00:28:01,713 and , in that case, you're gonna refer those patients to the ED just like you 586 00:28:01,953 --> 00:28:05,433 would for any hypertensive urgency, basically, or hypertensive emergency. 587 00:28:05,433 --> 00:28:07,743 It's a hypertensive emergency of pregnancy. 588 00:28:08,348 --> 00:28:08,798 Tracey: There you go. 589 00:28:09,308 --> 00:28:09,603 There you go. 590 00:28:10,193 --> 00:28:11,393 And the last take home point. 591 00:28:11,403 --> 00:28:14,937 Measure your blood pressures correctly, make sure they've been measured correctly. 592 00:28:15,067 --> 00:28:18,292 If you're Not happy with what that number is, maybe even go take it yourself. 593 00:28:18,582 --> 00:28:21,932 And make sure that the person was seated with both feet on the floor 594 00:28:21,932 --> 00:28:25,292 not talking, all those things that I just said and document, every time you 595 00:28:25,292 --> 00:28:28,172 take that blood pressure, that's an important key piece of information. 596 00:28:28,172 --> 00:28:29,612 And that should be in the medical record. 597 00:28:29,912 --> 00:28:31,742 Write it down in the EMR. 598 00:28:31,742 --> 00:28:32,642 Do whatever you need to do. 599 00:28:32,642 --> 00:28:33,782 Tell somebody else to do it. 600 00:28:34,062 --> 00:28:37,437 But you know, the more times you document that, the more 601 00:28:37,437 --> 00:28:40,197 times you'll have ammunition to say, Hey, this is hypertension 602 00:28:40,197 --> 00:28:41,517 and it needs to be dealt with. 603 00:28:41,827 --> 00:28:44,550 Back in the day, you know, all the charts were handwritten, it was 604 00:28:44,550 --> 00:28:47,010 really hard to go back and look at people's previous blood pressures. 605 00:28:47,010 --> 00:28:49,780 But now in the EMR you have it in all its glory. 606 00:28:49,780 --> 00:28:52,480 Every previous visit they ever had, you have their blood pressures 607 00:28:52,480 --> 00:28:54,820 all lined up in a row there, right there for you to look at them. 608 00:28:55,190 --> 00:28:57,990 So please look at them, it's important to do that. 609 00:28:58,260 --> 00:28:59,340 Very important to do that. 610 00:29:00,040 --> 00:29:00,820 Joe: Absolutely. 611 00:29:01,365 --> 00:29:03,605 So I heard we have something very interesting next month 612 00:29:03,805 --> 00:29:04,305 Tracey: Oh yes. 613 00:29:04,335 --> 00:29:05,115 MVAs. 614 00:29:05,175 --> 00:29:05,505 Yes. 615 00:29:05,505 --> 00:29:06,642 So excited about that. 616 00:29:06,642 --> 00:29:08,982 Motor vehicle accidents for the urgent care provider. 617 00:29:09,292 --> 00:29:10,492 A lot of interesting things. 618 00:29:10,502 --> 00:29:13,202 I bet you a lot of people are gonna find that they're not doing things 619 00:29:13,202 --> 00:29:14,762 exactly the way they should be. 620 00:29:15,112 --> 00:29:19,332 A lot of few interesting things and a lot of things to get rid of the scary 621 00:29:19,332 --> 00:29:21,162 management of a motor vehicle accident. 622 00:29:21,162 --> 00:29:24,162 I know there are some people out there that are so frightened by that. 623 00:29:24,162 --> 00:29:26,592 They send a lot of people to the emergency room, and then there are a lot of 624 00:29:26,592 --> 00:29:29,362 people that just kind of blow it off, so there's a nice middle ground and we're 625 00:29:29,362 --> 00:29:32,152 gonna, we're gonna talk about that and I'm really hoping that we can actually 626 00:29:32,152 --> 00:29:34,192 get the author to join us on that one. 627 00:29:34,502 --> 00:29:36,509 Like we did last month with the lab testing. 628 00:29:36,509 --> 00:29:38,710 So, very exciting things coming up. 629 00:29:38,710 --> 00:29:39,130 Joe: Mm-hmm. 630 00:29:39,445 --> 00:29:39,925 Can't wait. 631 00:29:40,075 --> 00:29:40,555 Tracey: Yeah. 632 00:29:40,855 --> 00:29:41,935 Thanks everybody for listening. 633 00:29:41,935 --> 00:29:44,365 We appreciate your time and have a great month. 634 00:29:44,777 --> 00:29:45,137 Joe: Yeah. 635 00:29:45,137 --> 00:29:45,767 Take care everyone. 636 00:29:45,817 --> 00:29:46,117 Bye-bye. 637 00:29:46,222 --> 00:29:46,442 Tracey: Bye. 638 00:29:46,998 --> 00:29:50,158 I want to thank everybody to listening to this month's evidence based 639 00:29:50,158 --> 00:29:54,559 urgentology podcast . Just a reminder that subscribers can go to ebmedicine.net 640 00:29:54,749 --> 00:29:58,299 and read the full issue if you want more information, if you haven't already, 641 00:29:59,197 --> 00:30:01,087 Joe: And if you're not a subscriber head to the site. 642 00:30:01,257 --> 00:30:04,027 That's ebmedicine.net to check out what they have. 643 00:30:04,351 --> 00:30:07,961 If you subscribe you'll get access to the article as well as future articles 644 00:30:07,981 --> 00:30:10,581 and the whole archive of all past issues. 645 00:30:11,034 --> 00:30:12,184 Tracey: Look forward to seeing you there.