What is the best course of treatment for a 47-year-old male with a history of essential hypertension, chronic pain, steatosis of liver, deep venous thrombosis, pulmonary embolism, migraine with aura, cervical lymphadenopathy, and pruritus, presenting with uncontrolled hypertension (blood pressure 179/108), currently taking suboxone (buprenorphine/naloxone) for chronic pain management?

Patient Note: 47-Year-Old Male Re-Establishing Care

Chief Concern & Immediate Action Required

This patient presents with a hypertensive urgency (BP 179/108 mmHg) requiring immediate oral antihypertensive therapy and close follow-up within 2-4 weeks, not ICU admission, as there is no evidence of acute target organ damage described. 1

Active Medical Problems Requiring Immediate Management

1. Uncontrolled Essential Hypertension - CRITICAL

• Blood pressure 179/108 mmHg represents severe hypertension (>180/120 mmHg threshold) but qualifies as hypertensive urgency rather than emergency given absence of acute end-organ damage symptoms. 1, 2
• Patient reports non-adherence to prescribed amlodipine, with documented uncontrolled hypertension dating back multiple years. 3, 4
• Immediate treatment: Restart amlodipine 10 mg daily immediately, with plan to add second agent (ACE inhibitor or thiazide diuretic) within 1-2 weeks if BP remains >140/90 mmHg. 5, 6
• Target BP <140/90 mmHg minimum, ideally <130/80 mmHg given multiple cardiovascular risk factors. 1, 5
• Critical: Reduce BP by no more than 25% within first 24-48 hours to avoid precipitating renal, cerebral, or coronary ischemia. 1

2. Chronic Pain Management with Suboxone

• Patient reports taking buprenorphine/naloxone 8mg/2mg once daily, though prescribed three times daily per system records. 7
• Reports appropriate disposal of excess medication at designated location. 7
• Pain sources documented: motor vehicle accident history, thoracic radiculopathy from intervertebral disc disorder. 7
• Suboxone prescribing should remain with current provider in external location; coordinate care but do not assume prescribing responsibility without proper DEA waiver and addiction medicine training. 7

3. Unexplained Chronic Lymphadenopathy - REQUIRES URGENT FOLLOW-UP

• Three-year history of cervical and inguinal lymphadenopathy with multiple incomplete workups and missed specialty referrals. 8
• Recent ER visits (×2 in last 4 months) for chest pain and right groin pain radiating to abdomen. 8
• Imaging findings: 1cm round mass adjacent to organ (likely lymph node), prominent lymph nodes in multiple locations, persistent right hilar lymph node. 8
• Action required: Obtain all records from recent ER visits and previous primary care provider immediately; verify status of hematology and oncology referrals; if not completed, place urgent referrals today. 8
• Differential includes lymphoma, chronic infection, autoimmune disease, or malignancy—requires definitive diagnosis. 8

4. History of Bilateral DVT and Pulmonary Embolism - ANTICOAGULATION STATUS UNCLEAR

• Patient reports discontinuing anticoagulation (medication name unclear, possibly warfarin or other agent) per provider recommendation in external location. 7
• Critical gap: No documentation of provoked vs. unprovoked VTE, duration of anticoagulation completed, or rationale for discontinuation. 7
• Recent bilateral lower extremity ultrasounds (×2 in last 4 months) reportedly negative for acute DVT. 8
• Action required: Obtain records documenting VTE workup, thrombophilia testing results, and anticoagulation management plan; consider hematology referral if unprovoked VTE or recurrent events. 7, 8

5. Hepatic Steatosis

• Documented on prior imaging (fatty infiltration of liver noted on multiple studies). 8
• Given pruritus presentation, order comprehensive metabolic panel, liver function tests, and consider hepatitis panel to rule out progression to steatohepatitis or other liver pathology. 8
• Pruritus can be early sign of liver disease progression; monitor closely. 8

6. Pruritus on Arms

• Physical exam: warm, dry, intact skin with small scabbed areas from scratching, no obvious rash. 8
• Treatment initiated: Topical corticosteroid and second-generation antihistamine appropriate as first-line therapy. 8
• If pruritus persists despite treatment, check liver function tests, basic metabolic panel, thyroid function, and consider dermatology referral for possible polycythemia vera or cutaneous T-cell lymphoma given chronic unexplained lymphadenopathy. 8

Hypertension Management Algorithm

Step 1: Immediate Initiation (Today)

• Amlodipine 10 mg once daily—patient must take immediately given BP 179/108 mmHg. 5, 6
• Counsel on medication adherence; non-adherence is the most common cause of uncontrolled hypertension. 3, 4

Step 2: Add Second Agent (Within 2-4 Weeks if BP ≥140/90 mmHg)

• For this patient, add lisinopril 10 mg daily (ACE inhibitor) OR chlorthalidone 12.5-25 mg daily (thiazide-like diuretic). 5, 6
• ACE inhibitor preferred given hepatic steatosis, as combination of amlodipine + ACE inhibitor provides complementary mechanisms and may reduce peripheral edema from amlodipine. 5
• Monitor serum potassium and creatinine 2-4 weeks after initiating ACE inhibitor. 5

Step 3: Add Third Agent if Needed (If BP Remains ≥140/90 mmHg on Dual Therapy)

• Add chlorthalidone 12.5-25 mg daily to complete triple therapy: ACE inhibitor + calcium channel blocker + thiazide diuretic. 5, 6
• This represents guideline-recommended triple therapy targeting three complementary mechanisms: renin-angiotensin system blockade, vasodilation, and volume reduction. 5, 6

Step 4: Resistant Hypertension Management (If BP Uncontrolled on Triple Therapy)

• Add spironolactone 25-50 mg daily as preferred fourth-line agent for resistant hypertension. 5, 4
• Monitor potassium closely when combining spironolactone with ACE inhibitor (hyperkalemia risk). 5
• Before adding fourth agent, verify medication adherence and screen for secondary hypertension causes: primary aldosteronism, renal artery stenosis, obstructive sleep apnea, NSAID use. 3, 4

Critical Diagnostic Workup Required

Immediate Labs (Today or Within 1 Week)

• Comprehensive metabolic panel (assess renal function, electrolytes, glucose). 1, 5
• Liver function tests (AST, ALT, alkaline phosphatase, bilirubin, albumin). 8
• Complete blood count with differential (evaluate for anemia, thrombocytopenia, leukocytosis/lymphocytosis). 1
• Lipid panel (cardiovascular risk assessment). 9
• Hemoglobin A1c (diabetes screening). 9
• Urinalysis with microscopy (proteinuria, hematuria assessment). 1
• Urine albumin-to-creatinine ratio (early renal damage marker). 1, 9

Secondary Hypertension Screening (If BP Remains Uncontrolled)

• Plasma aldosterone-to-renin ratio (primary aldosteronism screening). 3, 4
• Sleep study referral if symptoms of obstructive sleep apnea (snoring, daytime somnolence, witnessed apneas). 4
• Renal artery duplex ultrasound if clinical suspicion for renovascular hypertension. 3

Lymphadenopathy Workup (URGENT)

• Obtain all outside records from recent ER visits and previous primary care provider. 8
• Verify status of hematology/oncology referrals; if not completed, place urgent referrals today. 8
• Consider repeat CT chest/abdomen/pelvis with contrast if last imaging >6 months old. 8
• HIV testing (if not previously documented negative). 8
• Hepatitis B and C serologies. 8

Medication Reconciliation & Safety

Current Medications

• Buprenorphine/naloxone 8mg/2mg—patient reports once daily use, prescribed three times daily. 7
• Discrepancy requires clarification with prescribing provider; document patient's report of appropriate disposal of excess medication. 7

Medications to Avoid

• NSAIDs—significantly interfere with BP control and should be avoided or withdrawn. 4
• Immediate-release nifedipine—no longer acceptable for hypertensive urgencies due to risk of precipitous BP drops. 1
• Combining ACE inhibitor with ARB—increases adverse events without additional benefit. 5

Follow-Up Plan

Short-Term (2-4 Weeks)

• Recheck BP in office or arrange home BP monitoring (target <135/85 mmHg home readings = <140/90 mmHg clinic). 5, 6
• Review lab results and adjust medications accordingly. 5
• Reassess pruritus response to treatment. 8
• Verify completion of hematology/oncology referrals for lymphadenopathy workup. 8

Medium-Term (3 Months)

• Goal: Achieve target BP <140/90 mmHg (ideally <130/80 mmHg) within 3 months of treatment initiation. 5, 6
• Complete secondary hypertension workup if BP remains uncontrolled despite adherence to triple therapy. 3, 4
• Follow up on specialty referrals and obtain definitive diagnosis for chronic lymphadenopathy. 8

Long-Term

• Coordinate with suboxone prescriber regarding patient's goal of tapering off medication. 7
• Address cardiovascular risk factor modification: smoking cessation if applicable, weight management, sodium restriction <2g/day, regular aerobic exercise. 5, 9
• Annual monitoring of renal function, electrolytes, and cardiovascular risk factors. 9

Common Pitfalls to Avoid

• Do not delay treatment intensification for severe hypertension—prompt action required to reduce cardiovascular risk. 6, 2
• Do not assume lymphadenopathy is benign without definitive diagnosis—three-year history with incomplete workup requires urgent specialty evaluation. 8
• Do not prescribe suboxone without proper training and DEA waiver—coordinate with current prescriber. 7
• Do not restart anticoagulation without understanding indication, duration completed, and reason for discontinuation—obtain complete VTE records first. 7
• Do not add fourth antihypertensive agent before optimizing doses of first three agents and confirming medication adherence. 5, 3, 4