An Incomplete Workup

Early in my career I met Fran Dennison. She was a forty-something smoker with asthma and mildly elevated blood pressure. She seemed to always be under stress. A nontraditional university student, she was always trying to be in two places at the same time.

After several visits with elevated blood pressure readings, she became interested in doing something about it. Her routine chemistries and urinalysis were normal. She had normal heart and lung sounds and only a trace of ankle swelling.

My first choice of medications was a diuretic. She was eager to try it, and did her blood test as I had requested a couple of weeks after starting it.

At her next follow-up visit, her blood pressure was better, but not where it should be, so she agreed to also take an ACE inhibitor. I made her promise to get another blood test a week or two later, just to check on her kidney numbers. ACE inhibitors were brand-name drugs back then, and she asked for a 90-day prescription to keep her co-payment down.

Three months later Fran was back in the office, feeling terrible. Her complexion was pasty, almost jaundiced. Her face, hands and legs were puffy, and she had lost ten pounds due to nausea. She was exhausted and depressed.

I sent her for some bloodwork and promised to call her when the results came in.

Her liver profile was normal, but her potassium was high and her kidney function severely reduced. I called her and asked her to stop both the fluid pill and ACE inhibitor and to see me again as soon as possible.

Later that week I put my stethoscope to her abdomen and heard a faint, rhythmic hum over her abdominal aorta. The arterial pulses in her groins seemed fairly normal, but when I pumped up my blood pressure cuff on her right calf, her arterial pulse at the ankle disappeared somewhere just over 90. I got the same reading on her left leg.

“I know what’s wrong with you”, I explained. “You have coarctation of the aorta. The narrowing of your main artery is cutting off the blood supply to your kidneys, and that’s why your blood pressure in your arms is high. The kidneys are sending out chemicals to try to increase your blood pressure, and making it too high everywhere above the blockage, but it is still too low in your kidneys and in your legs.”

“Is that why my legs hurt when I walk?” she asked.

“Most likely”, I confessed. “I didn’t ask you if they did. I also didn’t listen to the arteries in your abdomen or check the blood pressure in your legs until now. And you didn’t get that blood test we talked about after you started the last medication I prescribed. That’s why we didn’t find out that the medicines were starving your kidneys of blood by lowering the pressure inside them too much.”

Fran’s kidney function returned to normal after we stopped her ACE inhibitor. Her blood pressure normalized after the vascular surgeons restored the circulation to the lower half of her body. Her leg aches disappeared and she started exercising. She even quit smoking.

Since that day I always check my hypertensive patients’ blood pressure in their legs and I always listen to their abdominal arteries

I have never come across another case like Fran’s, but if I do, I won’t miss it.

1 Response to “An Incomplete Workup”

  1. 1 Cathryn Delude April 20, 2011 at 12:19 pm

    How many things are doctors supposed to ask their patients about at a visit? Is this list growing? In addition, patients are constantly advised to “ask your doctor” about drugs, menopause, diagnostic tests, vaccines, etc. How do doctors handle all these topics without overlooking other possibilities, such as the leg blood pressure and adominal aortas as discussed in this blog? I’m writing an article about this issue and welcome comment and suggest sources.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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