Cardiology

PCP submission

Hi my patient is a 71 year old female w/ PMH of CKD stage 5 (GFR of 16) HTN HLD suspected CHF (she said she was told she had CHF at a hospitalization 2 years ago but has not been to cardiology and I have not been able to track down hospital records) sleep apnea hypothyroidism degenerative joint disease and depression. She also states that when she was hospitalized 2 years ago she was told she “might have COPD” but she has not followed up with pulmonology. Current meds include: Losartan 100mg Amlodipine 10mg Metoprolol ER 200mg Levothyroxine 75mcg Atorvastatin 20mg Fluoxetine 80mg and Albuterol PRN. She is a current smoker – smokes about 5 cigarettes a day. She’s 5’5″ 183 lbs. Has gained about 8 lbs in the past 3 months. Of note I see her in a clinic that serves homeless unstably housed and uninsured community members. Her BP has been consistently elevated – was 170/102 today – I have been trying to get her to start a diuretic for the past 6 months but she has issues with urinary incontinence and has been very hesitant to start. Today she said she is finally agreeable to consider starting a diuretic. Today she also shared that she has become increasingly short of breath over the past few weeks. She states she wheezes frequently and is using Albuterol 3-4 times a day with little relief. She is asking me for “a stronger inhaler than Albuterol” to help with her breathing.

I’m trying to get her to see cardiology, nephrology, and pulmonology, but given her socioeconomic status and some trust issues with hospitals (she is VERY hesitant to see any specialists), I think it may be a while before she gets in to see specialists. I’d love for her to get an ECHO and a chest x-ray, but again she has difficulty getting to any other clinics and is very anxious about seeing specialists. She seemed more open to a diuretic today – I was thinking about starting her on HCTZ.

Given her current situation would HCTZ be a reasonable addition to her medications? If so what dosing would you recommend? Or is there a different medication you think would be better to get her BP down? I’ve spent months building her trust and would love to be able to help her get her BP under control and maintain as much kidney function as possible. Is there anything else I can do in the primary care setting? Thanks!

Specialist response

Thank you for your question. A thiazide diuretic would be a very reasonable choice. You may want to start at a very low dose (eg. HCTZ 25 mg 1/2 tablet daily) to get her adjusted to it before going up to 25 mg. Best regards.