One of the interesting case about Hypertension where we had to manage the patient who was very reluctant to our treatment approaches.

1. Case Presentation:
Hypertension
PREPARED BY:
ANISH DHAKAL
(ARYAN)

2. Introduction
Mrs. M. T., a 70 years old female from Gorkha presented to
Gorkha hospital Emergency Department with complaints of
severe headache since morning
The headache was sudden in onset, intermittent in nature, dull
aching in character and 7/10 on visual analogue scale rating for
severity
No history of trauma, vomiting, photophobia, neck stiffness,
rash, visual symptoms, alcohol intoxication

3. No blurring of vision, no chest pain or heaviness, no
shortness of breath
No history of ischemic heart disease, stroke or chronic
kidney disease
Past history of COPD for 4 years (mMRC grade 2), HTN for 4
years. No other chronic illness. No surgical procedures
performed. Not under any medication at present. No
significant family history.

4. Risk Factors suggesting Serious Illness:
Age (70 years in the case)
Smoking (15 pack years)
Alcohol ( 1-2 glass locally made for last 50 years)
Salt intake (She loved salty foods and often added salt in pulse or/and curry)
Obesity (BMI was 24.03)
History of trauma
Systemic signs (fever, rash, stiff neck)
“Worst headache of my life” or change in frequency and severity
Known status of malignancy, HIV, immunosuppression
Focal neurological deficits
Diabetes mellitus

5. Examination:
GC: Fair, Moderately built
Vitals:
BP: 160/110 mm Hg (right) and 130/90 (left)
RR: 28 bpm
Pulse: 90 bpm, regular, normal volume, character, arterial wall
condition with no radioradial or radiofemoral delay
sP02: 93% in room air

6. Respiratory Examination:
Inspection: No visible deformity, scar marks, dilated veins,
No use of accessory muscles of respiration
Palpation: No tenderness, abnormal mass. Position of trachea
normal.
Percussion: Resonant note
Auscultation: B/L equal air entry with no added sounds
Cardiovascular examination:
S1, S2, M0
No raised JVP, apical impulse normal, no crepitation or swelling of
extremities

7. CNS Examination:
Well oriented to time, place and person
GCS: 15/15
Cranial nerves were grossly intact
Sensory and motor examination was normal
Reflexes were normal
No signs of meningeal irritation
No signs suggesting cerebellar lesions

8. GI Examination:
Inspection: Normal shape of abdomen, all quadrants moving equal
with respiration. No dilated veins, scar marks, pigmentation, visible
peristalsis. No any abnormal mass
Palpation: No local rise in temperature. Tenderness present on
deep palpation of RUQ.
Percussion: Each quadrant tympanic
Auscultation: Normal bowel sounds
PR examination was not done.

9. Differential Diagnosis:
Essential hypertension
Hypertensive urgency
Subdural hematoma
Subarachnoid hemorrhage
Hyperthyroidism

10. Investigations:
Complete Blood Count (TLC =10.1 * 103/mm3, N=77%, L=19%,
M=2%, L=2%)
Random Blood Sugar (106 mg/dL)
Renal Function Test (Urea: 20 mg%, Creatinine: 1.5)
ECG (Sinus rhythm)

11. Management
Tab. Nifedipine 10 mg PO stat
Daily BP monitoring and charting at local pharmacy and
advice for follow up after a week in OPD

12. Issues in Management:
The patient was very reluctant to any treatment approaches including medications,
ECG and blood test
In spite of the fact that she was diagnosed 4 years ago with HTN, she refused to take
any medications. Apart from current treatment previously she only accepted PCM for
occasional fever.
She said and I quote:
“एकपटक ओखति खाएपछी सधै खानुपछछ र ओखतिले मेरो जिउ लाई कमिोर बनाउछ ।
बरु म करेला र िडिबुटी खाएर बस्छु ।”
(Translation: Once I consume allopathic medicine, it would make my body very weak. I
would rather prefer bitter gourd juice and local herbal products”
On being asked the origin of her belief, she argued that that was the basic fact
everyone ought to find cure naturally and modern medicines and hospital had made
people’s mind more artificial and corrupted

13. Health Promotion Advice:
Age (70 years in the case)
Smoking (15 pack years)
Alcohol (1-2 glass locally made alcohol for last 50 years)
Salt intake

14. Salt Intake Reduction:
For adults: WHO recommends that adults consume less than 5 g
(just under a teaspoon) of salt per day
Not adding salt during the preparation of food
Not having a salt shaker on the table
Limiting the consumption of salty snacks
Choosing products with lower sodium or salt content

15. Role of Health Care Workers & Family:
She could have her blood measure regularly measured in nearest
health post
Family members could actively participate in reducing the risk
factor for her condition and aid in providing a healthy diet
Motivation and support for lifestyle changes including quitting
smoking and alcohol

16. Clinical Research Question:
Prognosis and long term outcomes of hypertension in
cohort of people refusing evidence based medicine and
adopting alternative medicine?

17. Self-Reflection
In the dominant era of evidence based medicine, people still tend to favor
alternative modes of treatment to the extent of completely refusing it
She stated: “िडिबुटटले अटिलेसम्म काम गररराथ्यो। आि एकचोटी नगरेर बल्ल
अस्पिाल आउनुपर्यो”
(Translation: Herbal products were working fine till date. I only needed to come to
hospital as they didn’t worked well today)
Though people’s opinion may seem outright invalid at the first sight, the need to
show respect, utter patience and tolerance
The role of counseling is to provide all facts and figures implying truth not always to
persuade or to guarantee the dynamic change in patient’s opinion
No “all or none phenomenon” in medicine. Even though the patient is not
compliant, to the very least we could still provide some health promotion measures
or non invasive monitoring of their health condition

18. https://health.10ztalk.com/2019/03/09/an-alternative-to-
alternative-medicine-anish-dhakal-aryan-medium/