Strange HTN case

"nursy", RN · Jan 7, 2020

I check my pressure at home and it's 130/80.. At the dentist 30 minutes later it's 179/100. I have white coat syndrome big time. That can be one possibility for your patient. Also, more and more the experts are emphasizing the correct way to take a BP is with a patient resting without talking or any stimulation for 5 minutes before the reading is done. Then recheck readings at the end of the visit, when the stress levels may have gone down. Also, if I take my own pressure several times in a row, they go down every time, as I sit quietly. So you take one reading in one arm and it's high, then a few minutes later the reading in the other arm is lower, cause the patient has been sitting quietly. Admittedly, that's just me. And you quite possibility have been doing everything perfectly, I just wanted to throw in the possibilities. Also I'm surprised there was no at home monitoring ordered. Other than that, the results of those tests will hopefully shed some light.

Gingeriffic · Jan 9, 2020

There shouldn’t be such a discrepancy between BPs taken on each arm.

The tests/imaging ordered seems aggressive for typical hypertension. Are there any specific reasons or findings prompting this work up?

How soon are tests going to be done?

Anonymous666 · Jan 25, 2020

On 1/8/2020 at 10:52 PM, Gingeriffic said:
There shouldn’t be such a discrepancy between BPs taken on each arm.

The tests/imaging ordered seems aggressive for typical hypertension. Are there any specific reasons or findings prompting this work up?

How soon are tests going to be done?

I was doing some reading, and it turns out there’ve been a few studies done that show it’s quite common for folks to have a difference between in arms, blood pressure-wise. The difference between arms growing larger as blood pressure rises.

The doc went straight for the CT scans d/t the huge difference between the arms.

All tests came back normal. No stenosis, no aneurysm. Pt’s BP is currently controlled with Norvasc 10 mg and Lisinopril 10 mg daily with daily exercise and diet changes. BP has leveled out at an average of 140/92 right arm and 120/82 left arm.

Lisinopril was titrated. When his BP was 120/80 in the right arm and 108/78 in the left, pt complained of dizziness and panicked feeling. HR was high 90’s. Pt’s normal HR is in the 60’s

Still strange... ??

LovingLife123 · Jan 25, 2020

So, my question is, why did they initially come in?

And did they do an echo?

Anonymous666 · Jan 25, 2020

26 minutes ago, LovingLife123 said:
So, my question is, why did they initially come in?
And did they do an echo?

Because their blood pressure was 180/120 in one arm and 148/98 in the other.

No echo. EKG was normal.

clemenine · Jan 25, 2020

The correct way on how to take accurate blood pressure is of paramount, to avoid false readings . AHA have a new guideline & there is a course in there website on Accuracy blood pressure measurements

Anonymous666 · Jan 26, 2020

Just now, clemenine said:
The correct way on how to take accurate blood pressure is of paramount, to avoid false readings . AHA have a new guideline & there is a course in there website on Accuracy blood pressure measurements

Yeah, that’s probably it—the patient, who’s a 12 year ICU nurse, the CNA; the NP; and the doctor are all making the exact same mistake when checking the blood pressure...

adventure_rn, MSN, NP · Jan 26, 2020

I'd definitely try to alternate which arm you check first to see if the readings were consistently higher. For instance, at your first check you'd do right arm first, next check you'd do left arm first, etc. As others have said, you'd definitely want to follow the guidelines to make the reading as accurate as possible.

If after all of that you were still getting a differential, I'd venture that it's some type of semi-occlusive arterial clot on side with the lower reading; I've seen this a handful of times on kids with femoral arterial clots post-cath. In peds, the diagnosis is done with a doppler ultrasound to evaluate both the presence of a clot and the flow of blood around it (i.e. how occluded the vessel is). However, depending on how deep the vessels are, they can be hard to access via ultrasound; in that case, I'm guessing that you'd eval with a CT angiogram (which @Gingeriffic might explain why they'd want so many vascular radiology studies). It would be a little weird to have bilaterally-equal distal pulses and perfusion in a case like that, but not unheard of.

It's interesting to me that they even realized the differential in the first place, since you don't routinely check pressures on both arms. I wonder if the nurse/tech who got the initial pressure thought it was so high that they assumed it was a fluke, then tried checking on the other arm and noticed the disparity.

Anonymous666 · Jan 26, 2020

Ok, for anyone who is still paying attention: I understand that this is “the internet.” However, this site is supposed to be a nursing community of nurses discussing nursing stuff.

The patient is an experienced ICU nurse.

He noticed the above blood pressures (see OP).

He went to the doctor.

CNA measured BP in both arms manually, NP measured BP in both arms manually, doctor measured BP in both arms manually.

Doctor skips US of subclavian arteries and goes straight for CT angiogram.

PT has two CT angiograms with and without contrast from the neck to the toes. The results show no stenosis, no aneurysms, no malformations. PLEASE READ THIS PARAGRAPH AGAIN BEFORE DECIDING TO RESPOND WITH A SUGGESTION OF CHECKING THE PT’s BP ACCURATELY OR GETTING A CT ANGIOGRAM.

I don’t feel like repeating myself again, so hopefully anyone paying attention or anyone with an ounce of reading comprehension is now aware of this patient’s current situation/medication regime.

if you have anything to add, please do

adventure_rn, MSN, NP · Jan 26, 2020

45 minutes ago, Anonymous666 said:
Ok, for anyone who is still paying attention: I understand that this is “the internet.” However, this site is supposed to be a nursing community of nurses discussing nursing stuff.
The patient is an experienced ICU nurse.
He noticed the above blood pressures (see OP).
He went to the doctor.
CNA measured BP in both arms manually, NP measured BP in both arms manually, doctor measured BP in both arms manually.

Doctor skips US of subclavian arteries and goes straight for CT angiogram.

PT has two CT angiograms with and without contrast from the neck to the toes. The results show no stenosis, no aneurysms, no malformations. PLEASE READ THIS PARAGRAPH AGAIN BEFORE DECIDING TO RESPOND WITH A SUGGESTION OF CHECKING THE PT’s BP ACCURATELY OR GETTING A CT ANGIOGRAM.

I don’t feel like repeating myself again, so hopefully anyone paying attention or anyone with an ounce of reading comprehension is now aware of this patient’s current situation/medication regime.

if you have anything to add, please do

Woah, calm down.

I read all of the posts, and I think there were just some miscommunications (both on your end and on ours).

We aren't saying that the blood pressures are necessarily inaccurate; we're just having a discussion about how they are often done in a way that's inaccurate, and we're describing different factors that can affect accuracy (i.e. checking one arm before the other, checking at the beginning of an appointment or the end, etc.) One of the great things about AN is that we can learn from one another through discussions like these. It doesn't mean that we're questioning whether or not it was done right. Even if the BPs in this scenario were perfectly accurate, other posters who read this might be be more accurate in how they get pressures in the future.

Also, yes, I read in you initial post that they're getting a CTA, and your follow-up that the CT showed differences in the arms. Another poster said they didn't understand why so many tests would be ordered in this scenario, and I was explaining why. It doesn't mean that we weren't reading your posts.

3 hours ago, Anonymous666 said:
Yeah, that’s probably it—the patient, who’s a 12 year ICU nurse, the CNA; the NP; and the doctor are all making the exact same mistake when checking the blood pressure...

For someone who is ranting in all caps about about reading comprehension, I had no idea what you were saying here. It definitely didn't clarify the situation (vs. your last post which, while over-dramatic, was much clearer). Perhaps if people aren't following what you're saying, you aren't explaining it well enough.

You posed a strange HTN case; we're weighing in on it. If these aren't the responses you're looking for, then I don't know what you want?

We are a community of professionals who are here to support one another; if you want to throw a tantrum, please take it to Reddit.

MunoRN, RN · Jan 26, 2020

29 minutes ago, Anonymous666 said:
Ok, for anyone who is still paying attention: I understand that this is “the internet.” However, this site is supposed to be a nursing community of nurses discussing nursing stuff.
The patient is an experienced ICU nurse.
He noticed the above blood pressures (see OP).
He went to the doctor.
CNA measured BP in both arms manually, NP measured BP in both arms manually, doctor measured BP in both arms manually.

Doctor skips US of subclavian arteries and goes straight for CT angiogram.

PT has two CT angiograms with and without contrast from the neck to the toes. The results show no stenosis, no aneurysms, no malformations. PLEASE READ THIS PARAGRAPH AGAIN BEFORE DECIDING TO RESPOND WITH A SUGGESTION OF CHECKING THE PT’s BP ACCURATELY OR GETTING A CT ANGIOGRAM.

I don’t feel like repeating myself again, so hopefully anyone paying attention or anyone with an ounce of reading comprehension is now aware of this patient’s current situation/medication regime.

if you have anything to add, please do

Sorry we're so stupid. But since your comprehension is so superior to the rest of us I'm sure you're already aware that the most likely cause of L vs. R arm blood pressure differences is due to subclavian stenosis, which can't actually be evaluated by CT scan, even though you claimed that stenosis had been ruled out by CT.