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  • 17 year old female obese patient with complex history and insurance coverage issues
  • PCP submitted eConsult for further management of care

eConsult Transcript

PCP submission

17 y/o F Had a subconjunctival hemorrhage in September, has not had this since then but has had some headaches. Was seen by a physician at this time and started on metoprolol succinate 25 MG ER. Did not see a big difference in her BP at this time and was only given one month supply and told to utilize lifestyle changes to lower blood pressure. Now, her higher BP and headaches mostly come in spurts and she can tell when her BP is high by her headache. 2-9 she could feel her heart racing and she took her BP 160/94 HR up to 130. States that the chest pain and higher heart rate is probably once a month but the elevated BP happens multiple times a week. Blood pressure is normal in the office today. The patient reports most of the time when she feels her BP high it is due to anxiety and has been having more anxiety lately due to sports starting back soon. Will wake up with anxiety.
Has been going to the gym, 4-5 x a week, cut out pop but has not lost any weight.
Vitals: BP 124/82, HR 100, Wt 219.4, BMI 40.13
PMH: Hypertension dx 09/2021, Seizures as a child due to birth trauma- no seizures since 6th grade, no medication for this. Seasonal allergies
Medication list: Cetirizine
Fam hx: Grandmother-kidney cancer, anxiety, Sister-Kidney cancer, Great grandmother-kidney cancer, Mother-anxiety, HTN on both mother and father’s side of the family

PE normal with exception of obesity. Long discussion about the importance of weight loss and cutting out salt to less than 2000 mg daily. Discussed the possibility of anxiety contributing highly to the blood pressure and tachycardia. Mother is open to treatment with anxiety medication. Going to cut back on salt, continue on working out, keeping a log with bp multiple times daily x 2 weeks for evaluation.

What agent do you think will be optimal for bp and heart rate control? I was thinking propranolol as this can also help with anxiety. However, I am also open to suggestions.

Do you think this patient needs a further work up with either kidney imaging/echo/stress testing? They do not have insurance so everything would be cash price but they are willing to do what is best.

Would she benefit more from an SSRI type medication for anxiety?

Thank you in advance for your consideration of these questions.

Specialist response

Hello, and thanks for the questions. This is definitely a very tough situation, it does seem that there is likely essential hypertension in this patient, exacerbated by anxiety and likely her obesity. However, there is a disturbing number of family members with renal disease, and this makes me uncomfortable making an assumption about any contribution of kidney pathology to her hypertension. Thank you for getting all of these labs, which look normal except for the Vit D levels. A renin and aldosterone level would also be useful to check here, and given the episodic nature of these surges in BP, it may be that urine HVA and VMA would be appropriate, even though this would be a rare abnormality. Metoprolol ER 25 mg is an extremely low dose for a patient with a BMI of 40. I would double that now to 50 mg easily, she may even need 100 mg. I would also recommend that she keep a food diary for a week, and take a picture of her meals and snacks to bring into the office to show you. I have a feeling that portion sizes are not being accurately measured and are keys to her inability to lose weight. Realizing there is an insurance issue here, I would want to minimize the amount of referrals. However, normally I would really recommend consulting a nephrologist before making any further medication recommendations beyond beta blockers especially with the family history.

There will be some need for renal imaging going forward, the family history puts her at higher risk for this cancer. I will say that I am not qualified to make a psychiatric recommendation remotely, and would not feel it is appropriate to make an assessment. This is hopefully a start. I hope that some of the other specialties on Rubicon might also be able to help guide some of these management decisions.

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