What is the best course of treatment for a 47-year-old male with a history of essential hypertension, chronic pain, steatosis of the liver, deep venous thrombosis, pulmonary embolism, migraine with aura, cervical lymphadenopathy, and non-cardiac chest pain, who is currently taking Suboxone (buprenorphine/naloxone) and has uncontrolled blood pressure?

PATIENT NOTE: 47-Year-Old Male Establishing Primary Care

CHIEF COMPLAINT

Establishing primary care; last seen in primary care 2-3 years ago.

HISTORY OF PRESENT ILLNESS

Cardiovascular History

Uncontrolled Essential Hypertension

• Blood pressure at today's visit: severely elevated (specific values documented in vital signs)
• History of uncontrolled hypertension dating back to documented dates in medical record
• Previously prescribed antihypertensive medication (specific agent documented) but reports non-adherence
• This represents a hypertensive urgency requiring immediate intervention 1
• Past workup included renal function testing to evaluate for secondary causes

Thromboembolic Disease

• History of bilateral lower extremity deep venous thrombosis 2, 3
• History of pulmonary embolism 2, 3
• Previously prescribed anticoagulation (specific agent documented) but reports discontinuation per provider recommendation in another state
• Requires urgent evaluation for recurrent thrombosis risk and consideration of anticoagulation resumption 2

Pain Management and Substance Use History

Chronic Pain Syndrome

• Related to documented underlying condition
• Previous opioid therapy including fentanyl patches
• Patient reports transition from prescribed fentanyl to illicit street fentanyl
• Currently on buprenorphine/naloxone (Suboxone) prescribed by out-of-state provider

Suboxone Management

• Prescribed dose: 8mg/2mg three times daily per prescription monitoring system
• Patient reports actual use: one 8mg/2mg strip daily
• Documentation of Suboxone use in medical record dating back to specific documented date
• Patient reports disposing of excess medication at local hospital
• Discrepancy between prescribed and reported use requires clarification and coordination with prescribing provider

Hepatobiliary

Hepatic Steatosis

• Documented on prior imaging
• Requires monitoring and lifestyle modification 1

Neurological

Migraine with Aura

• Active diagnosis requiring management

Lymphatic System

Chronic Lymphadenopathy

• Cervical lymphadenopathy documented since specific date
• Right inguinal lymphadenopathy with current increased pain radiating to abdomen
• Multiple prior workups including autoimmune and hematologic panels (reported negative)
• Reported negative testing for specific infectious etiologies
• Referrals documented to specialty services at specific facilities
• Remains without definitive diagnosis despite extensive evaluation

Musculoskeletal

Advanced Degenerative Joint Disease

• Bilateral hips: moderately advanced degenerative narrowing documented on imaging
• Bilateral ankles: advanced degenerative changes
• Contributing to chronic pain syndrome

Recent Acute Care Utilization

• Two emergency department visits in past four months for chest pain
• Workup included:
  • Bilateral lower extremity ultrasound (negative for DVT)
  • Right groin ultrasound for lymphadenopathy evaluation
  • Cardiac evaluation (non-cardiac chest pain diagnosis)

PAST MEDICAL HISTORY

1. Essential hypertension (uncontrolled)
2. Chronic pain syndrome
3. Hepatic steatosis
4. Bilateral lower extremity deep venous thrombosis
5. Pulmonary embolism
6. Migraine with aura
7. Cervical lymphadenopathy
8. Inguinal lymphadenopathy
9. Non-cardiac chest pain
10. Bilateral hip osteoarthritis (moderately advanced)
11. Bilateral ankle osteoarthritis (advanced)
12. Opioid use disorder (in treatment with buprenorphine/naloxone)

CURRENT MEDICATIONS

1. Buprenorphine/naloxone (Suboxone) 8mg/2mg sublingual strips
   • Prescribed: three times daily by out-of-state provider
   • Patient-reported use: once daily
   • Requires verification and coordination with prescribing provider

MEDICATIONS PATIENT SHOULD BE TAKING BUT IS NOT

1. Antihypertensive medication (specific agent documented in chart)

   • Patient reports non-adherence
   • Critical medication requiring immediate reinitiation given severely elevated blood pressure 1

2. Anticoagulation (specific agent documented)

   • Discontinued per provider recommendation in another state
   • Requires urgent reassessment given history of bilateral DVT and PE 2

ALLERGIES

No known drug allergies documented.

SOCIAL HISTORY

• History of transition from prescribed opioids to illicit fentanyl use
• Currently in medication-assisted treatment with buprenorphine/naloxone
• Reports appropriate disposal of excess Suboxone at local hospital

REVIEW OF SYSTEMS

Positive findings:

• Right groin pain radiating to abdomen (lymphadenopathy-related)
• History of chest pain (recent, evaluated in ED, determined non-cardiac)
• Chronic pain related to documented condition and degenerative joint disease

Negative findings:

• Patient denies current chest pain at this visit

PHYSICAL EXAMINATION

Vital Signs:

• Blood pressure: Severely elevated (specific values documented)
• This elevation meets criteria for hypertensive urgency 1, 4

Pertinent findings documented:

• Right inguinal lymphadenopathy with tenderness

DIAGNOSTIC STUDIES REVIEWED

Imaging Studies

CT Abdomen/Pelvis (dates documented):

• Questionable mild circumferential thickening of terminal ileum
• Possible mild terminal ileitis
• Several prominent lymph nodes in documented location
• Round mass adjacent to specific organ (felt to be documented finding)
• Mild soft tissue stranding around seminal vesicle/documented structure
• Small lymph nodes in documented location

Ultrasound Studies:

• Bilateral lower extremities: documented findings including bilateral documented condition
• No definite mass identified
• Small bilateral documented cysts

Chest Imaging (dates documented):

• No significant axillary or mediastinal lymphadenopathy
• Mild residual soft tissue density in anterior mediastinum (residual documented tissue vs. alternative diagnosis not ruled out)
• Persistent right hilar lymph node (slightly larger than previous)
• Fatty infiltration of liver

Hip/Pelvis Imaging:

• Symmetrical moderately advanced degenerative narrowing of both hips

Laboratory Studies

• Multiple autoimmune panels: reported negative
• Hematologic workup: reported negative
• Specific infectious disease testing: reported negative
• Renal function testing: performed in past for hypertension evaluation

ASSESSMENT AND PLAN

1. HYPERTENSIVE URGENCY - CRITICAL PRIORITY

Assessment:

• Severely elevated blood pressure without current evidence of acute target organ damage
• Long-standing medication non-adherence
• Requires immediate intervention to prevent progression to hypertensive emergency 1, 4

Plan:

• Immediately reinitiate antihypertensive medication (specific agent documented) - patient instructed to take today 1
• Target blood pressure <130/80 mmHg per current guidelines 1
• Given severity of elevation and chronic non-adherence, consider combination therapy with RAS blocker plus calcium channel blocker or thiazide diuretic as fixed-dose single-pill combination to improve adherence 1
• Recheck blood pressure in 1 week
• If blood pressure remains >140/90 mmHg after 3 months of lifestyle intervention and medication, escalate to three-drug combination 1
• Lifestyle modifications: sodium restriction <2,300 mg/day, weight reduction if indicated, regular aerobic exercise 30 minutes 5-7 days/week 1
• Screen for secondary hypertension given young age at diagnosis and resistant pattern 1

2. HISTORY OF VENOUS THROMBOEMBOLISM - URGENT PRIORITY

Assessment:

• History of bilateral lower extremity DVT and pulmonary embolism
• Currently not anticoagulated (discontinued per out-of-state provider)
• High risk for recurrent thrombosis, particularly given unprovoked nature and bilateral presentation 2, 3
• Recent negative bilateral lower extremity ultrasounds (within 4 months)

Plan:

• Urgent evaluation for resumption of anticoagulation therapy 2
• Direct oral anticoagulants (DOACs) are first-line treatment options due to lower bleeding risk compared to vitamin K antagonists and ease of use 2
• Obtain records from provider who recommended discontinuation to understand rationale
• If thrombosis was unprovoked or secondary to persistent risk factors, extended anticoagulation beyond 3 months should be strongly considered 2
• Assess for underlying thrombophilia or malignancy given chronic lymphadenopathy
• Consider hematology consultation for thrombosis risk stratification

3. OPIOID USE DISORDER ON MEDICATION-ASSISTED TREATMENT

Assessment:

• History of prescribed opioid use transitioning to illicit fentanyl
• Currently on buprenorphine/naloxone with documented use since specific date
• Discrepancy between prescribed dose (TID) and patient-reported use (daily)
• Patient reports goal of discontinuation

Plan:

• Coordinate care with out-of-state Suboxone prescriber to clarify dosing discrepancy
• Verify patient's report of excess medication disposal through local hospital pharmacy
• Continue current buprenorphine/naloxone therapy - do not abruptly discontinue
• Discuss tapering plan with prescribing provider when patient is medically stable
• Utilize prescription drug monitoring program for ongoing surveillance
• Provide harm reduction counseling
• Consider referral to local addiction medicine specialist for care coordination

4. CHRONIC LYMPHADENOPATHY - UNDIAGNOSED

Assessment:

• Cervical and inguinal lymphadenopathy for at least 3 years
• Extensive prior workup including autoimmune, hematologic, and infectious disease testing (reported negative)
• Current right inguinal pain radiating to abdomen
• Documented referrals to specialty services at specific facilities
• Concerning for occult malignancy, particularly lymphoma, given chronicity and multiple sites 5

Plan:

• Request all records from documented specialty referrals and recent ED visits immediately
• Review all prior imaging and laboratory studies once obtained
• If specialty evaluation has not occurred, expedite referral to hematology/oncology
• Consider repeat CT chest/abdomen/pelvis with contrast if not recently performed
• May require lymph node biopsy for definitive diagnosis
• Follow up on documented referral status within 1 week

5. CHRONIC PAIN SYNDROME

Assessment:

• Multifactorial: related to documented underlying condition plus advanced bilateral hip and ankle osteoarthritis
• Currently managed with buprenorphine/naloxone
• Pain may be contributing to elevated blood pressure 6

Plan:

• Continue buprenorphine/naloxone as prescribed by specialist
• Non-opioid adjuncts: consider acetaminophen, topical NSAIDs for joint pain
• Physical therapy referral for hip and ankle osteoarthritis
• Weight reduction if indicated to reduce joint stress
• Orthopedic evaluation for consideration of hip arthroplasty given moderately advanced bilateral disease
• Pain management consultation if not already established

6. HEPATIC STEATOSIS

Assessment:

• Documented on prior imaging
• Risk factors may include metabolic syndrome components

Plan:

• Lifestyle modifications: weight reduction if overweight, limit alcohol consumption, increase physical activity 1
• Screen for metabolic syndrome components: fasting glucose, lipid panel
• Repeat liver function tests
• Consider hepatology referral if transaminases elevated or evidence of fibrosis

7. MIGRAINE WITH AURA

Assessment:

• Active diagnosis
• Current management unclear

Plan:

• Assess frequency and severity of migraines
• Optimize preventive therapy if frequent (>4 per month)
• Ensure appropriate abortive therapy available
• Blood pressure control may improve migraine frequency

8. NON-CARDIAC CHEST PAIN

Assessment:

• Recent ED evaluations (x2 in past 4 months) with negative cardiac workup
• May be related to musculoskeletal causes, anxiety, or gastroesophageal reflux

Plan:

• Review ED records when obtained
• If recurrent, consider gastroenterology evaluation for GERD
• Reassurance regarding negative cardiac workup
• Monitor for recurrence

9. HEALTH MAINTENANCE

Plan:

• Request all records from previous primary care clinic and recent ED visits
• Update immunizations per ACIP guidelines
• Age-appropriate cancer screening: colonoscopy if not up to date
• Lipid panel, hemoglobin A1c, comprehensive metabolic panel
• Urinalysis given hypertension history
• ECG given hypertension and history of chest pain
• Establish care with local specialists as needed

FOLLOW-UP

• Blood pressure recheck in 1 week - CRITICAL
• Follow up on specialty referral status within 1 week
• Establish care visit in 2-4 weeks once records obtained and initial interventions implemented
• Patient instructed to return to ED immediately if chest pain, shortness of breath, leg swelling, neurological symptoms, or blood pressure symptoms (severe headache, visual changes) develop 4

CRITICAL ACTION ITEMS

1. ✓ Antihypertensive medication prescribed - patient instructed to take immediately 1
2. ⧗ Request all outside records (previous primary care, specialty referrals, recent ED visits)
3. ⧗ Coordinate with out-of-state Suboxone prescriber regarding dosing discrepancy
4. ⧗ Urgent evaluation for anticoagulation resumption given VTE history
5. ⧗ Follow up on documented specialty referrals for lymphadenopathy
6. ⧗ Blood pressure recheck in 1 week

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This patient requires intensive care coordination given multiple complex medical issues, medication non-adherence, undiagnosed lymphadenopathy, and critically elevated blood pressure. Immediate priorities are blood pressure control and evaluation for anticoagulation resumption, with close follow-up essential to prevent cardiovascular complications. 1, 4, 2