Case Presentation: Hypertension (A case on refusal of Evidence Based Medicine)

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 * 10 3 /mm 3 , 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 खानुपर्छ र ओखतिले मेरो जिउ लाई कमजोर बनाउछ । बरु म करेला र जडिबुटी 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 N ot adding salt during the preparation of food N ot having a salt shaker on the table L imiting the consumption of salty snacks C hoosing 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: P rognosis 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: “ जडिबुटिले अहिलेसम्म काम गरिराथ्यो। आज एकचोटी नगरेर बल्ल अस्पताल 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 / Thank You