Made for Medicine

One of my patients in the ICU is a young woman with hypertension, chronic kidney disease, crack cocaine use, and a seizure history who presented with a very bad intracerebral hemorrhage. She's still in a coma; she's not getting better. It is a sad story, and currently we're continuing aggressive care per wishes of the family because she is only in her 30s and has two children. However, one of her ongoing problems is her hypertension. She is currently on five anti-hypertensive medications: amlodipine 10mg daily, clonidine 0.4mg TID, labetalol 900mg TID, minoxidil 2.5mg BID, and a nicardipine drip. She's maxed out almost all her medications; because of her chronic kidney disease, we're avoiding renal-active drugs. Nevertheless, her systolic pressures still run into the 220s.

One afternoon, I had a little free time so I decided to think about causes of refractory hypertension. It could simply be due to the kidney disease, but I wanted to rule everything else out. I reviewed her extensive records and found that she had been worked up in the past for Cushing's, Conn's, thyroid disorder, and even pheochromocytoma. She had a normal renal ultrasound in 2003, but I wondered if we should do more investigation into renal artery stenosis, a common cause of secondary hypertension. I off-handedly put it in my note, but since ICU doesn't handle that kind of work-up, I didn't push for it. This morning, the neurology fellow said she read my assessment and plan and liked it. "It was a very medicine note," she said. I realized, even in this non-medicine rotation, I keep a bit of that thought process.