When to Follow Up With a Patient: Hypertension Case Study for New Nurse Practitioners
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Show notes:
One of the first things I encountered as a new nurse practitioner seeing patients on my own was the decision-making process of when to bring a patient back to the clinic again at the end of the visit.
The most unhelpful answer to this question? It depends!
But actually there is a framework you can use to answer this question for each patient sitting in front of you.
Hypertension Management in Primary Care
In this week’s video, I’m using a case study of a patient with hypertension and the management options to illustrate how to address this question in your own practice with any patient that comes into your clinic.
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well hey there it's liz rohr from real
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world np and you're watching np practice
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made simple the weekly videos to help
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save you time frustration
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and help you learn faster so you can
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take the best care of your patients so
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in this video
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i want to talk about medical decision
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making as it relates to when people come
Overview
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back like when to tell them to come back
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when to follow up in the context of
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being a newer clinician
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but also giving the example of
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hypertension management because
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i tried to talk about it without a
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clinical context and it didn't really
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quite make sense
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so this is a combination of both things
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and it's very high level hypertension
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management because
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i can definitely get into pharmacology
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in that management but that's definitely
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like a separate
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topic because it's really it's a lot so
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in this video i'm going to give you an
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example
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of hypertension management various
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different scenarios of cases
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and the general frameworks and rules
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that i use for
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for following up with patients and
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knowing when to have them follow up so
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the example i want to start with is
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somebody with hypertension
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of course i've already said that but
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somebody who like how i approach
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when to have people follow up and the
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general rule
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there's a quote unquote rule this is
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also the way that i approach medicine
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basically for every like when we're in
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school we learn the foundations right
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the foundations of like the core of what
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we need to know but
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our jobs as new clinicians is to
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understand like what's in this big
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bubble
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of primary care what are those threads
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for each of those little tiny
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origin stories in the beginning right of
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hypertension diabetes etc
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cetera following those threads in terms
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of the algorithms the management et
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cetera et cetera
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and then like what is outside the scope
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of primary care into
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specialty care into the hospital setting
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you know so we start with that
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but we have to we have to build and
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build so the short answer
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of knowing when to follow up with
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somebody is dependent it depends
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which is not helpful right but it's
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really dependent on the condition that
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you're looking at but the
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other potential pearl that you can apply
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the framework that i use
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is when i'm learning going from those
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foundations to those following those
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threads into like the full
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depth of what i need to know in primary
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care i'm really looking at
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looking at it from the perspective of
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each condition what is the worst case
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scenario
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and what is the best case scenario and
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this ties into when to follow up with
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somebody because when you understand the
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best case and worst case scenario for
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the condition that you're looking at
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it will give you a sense of that
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spectrum of how soon to see them again
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and there's a lot of philosophy of
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practice and a lot of clinical decision
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making involved here so it's not simple
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it's not a simple thing unfortunately
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but
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hopefully these examples will illustrate
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what i'm talking about and
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help you translate that into your own
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practice and also
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identify your own philosophy of practice
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right because we all have our own
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philosophies of what we feel comfortable
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with and not
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regardless of how much experience we
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have right i hope to identify these a
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little bit more clearly but
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um anyway if you're already if you're a
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student or if you're already in practice
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you probably have seen how different
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providers do things a little bit
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differently despite having the same
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guidelines
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right so anyway getting into the example
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so somebody for example has hypertension
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right they come to you in your clinic
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and their blood pressure is 150 over 90.
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say
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it's a you know 50 year old cis male
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patient right
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there's a couple things you want to
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think about when it comes to
Worst Case Scenario
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hypertension what is the worst case
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scenario
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so the worst case scenario of
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hypertension is hypertensive urgency
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emergency
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where your blood pressure is so high
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it's causing end organ damage
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right so heart attack stroke you know
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it's
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you're assessing for the signs and
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symptoms of end organ damage you're
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looking at
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endoscopy which is challenging but if
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they have any papilloedema
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do they have a headache vision change
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vision changes
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chest pain dizziness like do they have
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any signs of like
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neuro cardiac and organ damage right
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because it's not the number that's the
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problem it's the effects of the problem
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the effects of the number that are the
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problem right so that's the worst case
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scenario
Best Case Scenario
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so the best case scenario is somebody
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has hypertension for example one option
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of a best case scenario is somebody
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who has hypertension taking one
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medication taking it every day
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and their blood pressure has been the
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same over the last like three years on
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that same medication
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and they're exercising they're following
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a healthy dash diet or similar healthy
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diet mediterranean diet et cetera
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and they come to their appointments
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regularly we see them once a year
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maybe twice a year but usually once a
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year for those stable like
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well-managed hypertension patients so
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that's the spectrum here right
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so when it comes to deciding when to
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follow up it's inside of that context
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right so i for example have somebody
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whose blood pressure is 150 over 90.
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depending on the guidelines that you're
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looking at they've been a little bit
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updated and contentious the jnc 8
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guidelines compared to the newer ones
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that are not
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fully adopted by everybody yet the range
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of what the quote-unquote goal is is
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different
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right but regardless 150 over 90 is not
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in anybody's goal regardless of what
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we're talking about save 160 over 90
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right so this is not it goal
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so that there's a couple pieces here in
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terms of the follow-up and the
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management right
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so it's kind of two pieces in this video
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so one is like where does this person
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fall on the spectrum
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of like best case scenario to worst case
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scenario this patient is not quite
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at the place of worst case scenario
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right because hypertensive urgency
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emergency is typically around 200 over
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120
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something like that and then they're
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having all those symptoms right so this
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patient we're assessing
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do you have any signs of hypertensive
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urgency right you're asking all those
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clinical signs
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and symptoms if they're fine then we're
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not really at that place right
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we still need to act we still need to do
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something for them
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and so the the decision of when to
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follow up is what you decide to do so
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let's
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let's take a pause there for a second
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and talk about hypertension so when it
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comes to hypertension assessment and
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management
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you're looking at a couple of things are
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you taking how often are you taking your
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medications how often do you remember to
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take your medications i personally love
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phrasing the question that way because
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it's less
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there's less judgment less risk of
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judgment when somebody answers that
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question because
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we all forget right i think we assume
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that everyone you know is prescribed to
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med and then they take it every day but
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that's that's not real life right
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so how often do you remember to take
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your medications right are you what kind
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of exercise are you doing what other
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data do we have what is the heart rate
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what is the blood pressure
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um what is their bmi because we know
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that higher bmi
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bmi's over 25 are can be associated with
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higher blood pressure as a potential
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risk factor what kind of exercise are
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they doing what is their diet like
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do they check their blood pressure at
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home right because with hypertension
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they can have this like kind of
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quote-unquote white coat hypertension
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where it's only high when they're in the
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clinic
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but then it's lower when they're at home
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and if they check their blood pressure
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at home
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how are they measuring it right are they
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doing a wrist cuff are they doing an arm
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cuff what times of day
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are they like sitting with their feet on
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the floor which is the way we're
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supposed to be measuring it right
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when they're in the clinic have you
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measured it the correct way is it the
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correct cuff size right
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there's a lot of things to think about
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and assess and i say that all because
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that whatever the assessment is of like
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what you feel like is contributing to
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the high blood pressure that day
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will influence when you decide to have
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them come back in addition to
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how close they are to the hypertensive
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urgency situation right
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so for this patient they gained 10
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pounds since you last saw them
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a year ago and previous to that time all
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their blood pressures are 130 over 80 or
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120 over 70.
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they always check their blood pressure
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at home um they just stopped because
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they felt like it was controlled for so
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long or will manage for so
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long so they may have gained some weight
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with covadig and quarantine
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you have a conversation about hey can we
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talk about body weight i notice that
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your weight is 10 pounds higher than it
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was before
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and we know that that can contribute to
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elevated blood pressure so i'm wondering
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if that's contributing to what's going
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on with your blood pressure today
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after i've already assessed with them
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those other questions how often are you
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taking your medications
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what are you taking et cetera et cetera
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so for that example of that particular
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patient
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they're taking their medications they're
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very concerned about their high blood
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pressure
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and we have that conversation and
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they're like you know what i'd much
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rather
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i'm gonna pause it for a second when
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you're the clinician if you have
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something in front of you there's some
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sort of intervention you're doing
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right and it doesn't always have to be
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adding another medication you're
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thinking about all the options right so
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you talk about the options of the
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patient do you want to
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think about lifestyle modification do
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you want to think about attempting some
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weight loss do you want to think about
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medication adherence reminders do you
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want to take another medication instead
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because your life is too crazy right now
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to even think
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about attempting to lose weight because
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you're just keeping your head above
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water
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right because we're still in the
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pandemic at the time of recording of
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this video
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there's a lot of thinking going on here
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there's a lot to manage it's also
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highlighting why it's so hard to be a
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new clinician right there's a lot going
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on here that i'm rattling off because
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i've been in practice for several years
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and i've done this like thousand million
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times right so let's go back to like
When to Follow Up
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when to follow up
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right putting these both together so you
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have this conversation with this patient
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you come up with an intervention of some
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kind right potential interventions
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depending on your patient and depending
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on the history you've gathered so far
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this particular scenario this person is
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more interested
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in bringing their weight back to where
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it used to be 10 pounds ago
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than they are with taking a new
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medication right so there's a
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menu of options here right so what we
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can do
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is give that a try um i typically
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recommend for patients that we monitor
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their blood pressure at home with a cuff
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if they can afford it if they can't then
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that's okay
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and have them follow up in a couple of
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months right because how
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number one how close are they to the
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urgency situation not that close
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what scenario and hypertension is going
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to make this person's blood pressure go
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from 150 all the way up to 100 over 220
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or 220 over 100
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right that's not that likely anything is
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possible on medicine right which is why
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i always conclude my visits talking
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about alarm signs and symptoms like hey
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i asked you about all of these things
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please watch out for those things if you
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experience any of those things please
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let us know
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headache chest pain vision changes like
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pers like severe headaches like things
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like that
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check your blood pressure if you notice
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those things if you have a cuff at home
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or just let us know
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right so the likelihood of them going
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from the kind of like middle range of
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best case scenario to worst case
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scenario it's unlikely for this clinical
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situation for them to
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skyrocket up to 200 over 100 or whatever
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and
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have hypertensive urgency so for that
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patient lifestyle intervention is gonna
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take
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some time right so i'm not gonna see
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them next week i'm not gonna see them in
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a month
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i'm probably gonna wait until three
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months right because it's slightly above
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the the goal range the intervention is
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going to take some time
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they know the alarm signs and symptoms
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however the caveat i want to make here
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is that you are your own clinician and
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you get to decide right
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because when i was a new grad the
9:58
thought of waiting three months to see
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somebody again felt like a lifetime
10:01
and i was like are they gonna even make
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it right and which is which is a silly
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thing to say because the
10:06
situations i was looking at were not
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severe situations where that was
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even an option but i was so nervous as a
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new clinician i wanted to see everybody
10:13
tomorrow you know so you kind of have to
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just make that decision for yourself
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the reason so let's just turn that
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situation a little bit right so this
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person has hypertension comes in with a
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blood pressure of 200 over 100
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talking about that range she is he or
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she i guess i'm
10:27
sticking with the same person he is
10:29
closer to that hypertensive urgency
10:31
situation this literally happened to me
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last week the person comes in has this
10:34
alarming blood pressure i'm asking those
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same history questions i'm looking at
10:37
the trends over time
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this person has always had quote unquote
10:40
always had high blood pressure
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doesn't check their blood pressure at
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home and has no signs and symptoms of
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hypertensive urgency we've done an ekg
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we've assessed for all of the things
10:50
that we're looking for they feel fine
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and this might be a little bit
10:53
contentious but the evidence supports
10:55
that we don't need to send somebody to
10:56
the er with that blood pressure just
10:58
because of the blood pressure
10:59
because we don't chase down blood
11:01
pressures urgently unless they have
11:03
signs of hypertensive urgency right
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so for this patient i'm really
11:06
uncomfortable but i don't need to send
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them to the er because i've seen it
11:09
enough times that they don't do anything
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there aside from doing ekg and assess
11:13
for the signs of enormous organ damage
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if i don't feel comfortable assessing
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that then i'll send them right but if i
11:18
assess them and i feel comfortable with
11:20
that
11:20
we're just gonna manage them right but
11:22
the follow-up is a lot closer
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right because this person is a lot
11:25
closer to the worst case scenario
11:27
and it could change quickly right
11:30
because it might just be a few points
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until she gets he or she i'm thinking of
11:33
another patient
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that she is if i keep saying she but um
11:36
until he feels
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until he doesn't feel well but we're
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going to choose an intervention and
11:40
we're going to choose a quickly acting
11:42
intervention because we want to get that
11:44
down sooner
11:44
right we don't have to chase it down
11:46
right now right again that maybe that's
11:48
a separate video to talk about
11:49
hypertensive urgency and
11:50
and emergency and all that but whatever
11:53
intervention you choose typically some
11:54
sort of medication management
11:57
you're going to see them a little bit
11:58
sooner and it depends on the half-life
12:00
of the medication that you're talking
12:01
about it depends on a couple of
12:03
different things but
12:03
there's no hard and fast you have to see
12:05
them tomorrow you have to see them the
12:07
next day
12:07
my comfort is that they check their
12:09
blood pressure at home again if they can
12:10
afford a blood pressure cuff which is
12:12
wild that insurance does not cover these
12:14
but
12:14
anyway that's neither here nor there but
12:16
they check their blood pressure at home
12:18
and i see them within a week maybe they
12:20
check in with the nurses in two days or
12:21
three days and they check their blood
12:23
pressure there they check their blood
12:24
pressure at home
12:25
um and we've done some sort of
12:27
intervention to
12:28
to bring it closer to the lower level
12:30
right
12:31
and then i guess one last thing i want
12:33
to say that's like the general gist of
12:35
hypertension management
12:36
and in the context and maybe it's not
12:39
completely covering all the different
12:40
options as it comes to hypertension
12:41
that's the kind of quick and dirty way
12:43
to
12:43
approach hypertension management aside
12:45
from the guidelines and meds and all
12:46
that stuff
12:47
um but that's like the general approach
12:49
as i take to um
12:50
when to tell people to come back advise
12:52
them recommend that they come back
12:53
because they're adults they get to
12:54
choose not to they don't want to
12:55
but like just just very briefly thinking
12:58
switching it to a different scenario
12:59
talking about cellulitis so i have a
13:01
video about cellulitis i can link to
13:02
down below this video
13:03
that clinical situation is potentially
13:05
different right the risks are different
13:07
the the rate and the of of progression
13:10
to the worst case scenario is a little
13:12
bit more rapid potentially than
13:14
somebody with long-standing chronic
13:15
hypertension so if i'm really depending
13:18
again on the risk factors and the
13:19
assessment that you're doing but if they
13:20
have diabetes
13:21
they're at higher risk for spread of
13:23
infection they're a higher risk for
13:24
osteomyelitis
13:25
i'm going to do a little bit of a
13:26
tighter overseeing and management of
13:28
that person
13:29
i might see them the next day or two
13:31
days later or three days later
13:33
knowing that for it to show complete
13:35
resolution can take some time but i do
13:37
want to make sure that it's not
13:38
progressive
13:39
right i want to make sure that any
13:40
antibiotics i start for somebody with
13:41
cellulitis
13:42
number one is appropriate right
13:44
depending on their history and the risk
13:45
factors and all that stuff
13:46
and i'm making sure that they don't need
13:48
to go to the er but if they're
13:49
appropriate to be an outpatient
13:50
i'm probably going to outline the wound
13:52
on their leg and i'm going to have them
13:54
come back in the next day or two days
13:56
and then kind of follow them a little
13:57
bit more closely but anyway if there's
14:00
one kind of like takeaway that you can
14:01
take in terms of when to follow up with
14:03
patients is just
14:04
doing your best to identify in the
14:05
clinical situation what is the absolute
14:07
worst case scenario
14:08
how close are they to that how would i
14:10
know and what is the likelihood that
14:12
they're rapidly going to progress to
14:13
that how quickly would they rapidly
14:15
progress
14:16
to that depending on that condition and
14:18
kind of working your way backwards
14:20
so alternatively you can just ask so
14:23
that's what i did
14:24
a lot of the time when i was a new grad
14:26
so hopefully this clarifies
14:28
some questions about when to have
14:31
patients follow up
14:32
and like the general like real world
14:34
translation of one particular
14:36
scenario like we learned about things in
14:39
school that like we learned about
14:40
hypertension management
14:41
but like what does it actually look like
14:43
in real in the real world
14:44
right and so hopefully those two things
14:47
were helpful today
14:48
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15:00
anywhere else anyway let me know what
15:02
questions you have thank you so very
15:04
much for watching
15:05
hang in there and i'll see you soon
15:16
you
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