CASE STUDIES Martin Cassidy Yassir Javaid Wednesday 16 th March 2016
Case Study 1 Male Aged 44 Family History of stroke due to AF
How did you first come aware that your blood pressure was high? What happened when you went to see your GP? I went to see GP over concerns with mother having had an stroke due to atrial fibrillation, and having taken high readings myself on a home BP meter. What action should GP take?
How did the GP diagnose you with high blood pressure? The GP took a reading then and asked for me to do a 24hr BP monitor. What was your blood pressure at time of diagnosis? Ambulatory BP Monitor - BP was around 144/90 What action should GP take?
What treatment did the GP put you on and what was his rationale? What explanation was given to you about the medication and why you should take it? Step up doses of Ramipril, 2.5mg / 5mg / 10mg, she said that I was only getting older and the BP would only rise and that we should get it down by medication then if we can improve it by other means I can come off it.
What is your blood pressure currently? Around 128/78 on list readings, lowest was 116/70 around December but been a little stressed lately. Only on 5mg of Ramipril at present. What action should GP take now?
What improvements would you suggest to how your blood pressure was diagnosed and is being managed? Some GP s seem more switched on than others and my GP diagnosing it was very switched on. Suggesting that patients monitor there own BP as monitors are relatively cheap and email over data would be a help in time for patient and GP. Although my GP will do this, it does not seem to be an accepted or used way.
Case Study 2 Male Aged 52 Family History Father had angina when 70 plus and a stroke when 80 plus
How did you first come aware that your blood pressure was high? What happened when you went to see your GP? Home BP monitor had taken readings for a long period Went to GP who suggested patient see Practice Nurse to have BP readings taken over period of 3 to 6 months 15 May 2015 = 139/96 23 June = 136/93 29 June = 130/80 22 July = 134/93 Diastolic BP readings by PN were high Patient readings also showing consistent high diastolic readings What action should PN & GP take?
How did the GP diagnose you with high blood pressure? Sent to hospital for ambulatory BP monitor test What was your blood pressure at time of diagnosis? Ambulatory BP Monitor result in August 2015: Awake reading 129/96 Asleep reading 140/80 What action should GP take?
What treatment did the GP put you on and what was his rationale? What explanation was given to you about the medication and why you should take it? GP stated that although the diastolic BP reading was high that they did not recommend medication. Adding the revised BP score did not change the 10 year CVD risk significantly also added in a cholesterol reading of 6+ from work based health check which did not change CVD risk
Advised by GP to Reduce salt intake do not add salt to food Exercise more informed GP difficulty in exercising due to tarsal tunnel awaiting operation Alcohol intake within unit limits Received no written information
What is your blood pressure currently? Reading 14 March 2016 at pre-op assessment of 136/98 Operation scheduled for 6 th April 23 days away Advised to see GP as diastolic reading higher than anaesthetist would consider operating on (90) if too high on morning of operation the op may get cancelled on the day Patient saw GP on same day GP took BP - reading of 140/100 What action should GP take now?
What happened in GP consultation? GP asked patient what they would like to see happen? Patient requested medication to help lower the blood pressure to enable operation to proceed and following foot operation would be able to increase exercise with potential to then come off the medication GP agreed and prescribed 2.5mg Ramipril capsules
GP Advised patient to: Commence taking home BP readings (morning and evening lower of 2 readings 1 minute apart) See GP in one month s time & see Practice Nurse in 2 weeks to take blood pressure reading and blood test for egfr function Patient given Medicines & Your Kidneys Leaflet as commencing taking Ramipril GP consulted GP notebook on management protocol also looked on CCG website for local hypertension guidelines but none available At Chemists patient offered New Medicines Review telephone call at 7 & 14 days
What improvements would you suggest to how your blood pressure was diagnosed and is being managed? Standardised information for patients on how to reduce blood pressure Follow-up of those with high blood pressure particularly where no medication provided in order to review blood pressure Encourage home monitoring and reporting to GP surgery Consider holistic patient needs inability to significantly increase exercise Access to GP guidelines on management of blood pressure? (review what is in GP notebook)