Poorly Controlled Hypertension and Diabetes in a Woman Caring for a Grandchild
Mrs A is a 52-year-old widow who sells vegetables in a busy market and cares for her 6-year-old grandson, who has asthma. She attends the clinic after missing three of her last five appointments. Her blood pressure is 172/106 mmHg on two readings, and her latest HbA1c is 9.4%. Serum creatinine is 132 µmol/L, estimated GFR 48 mL/min/1.73 m², and urine albumin-to-creatinine ratio is 85 mg/mmol. She reports fatigue, dizziness on standing and blurred vision. She takes amlodipine 5 mg daily and metformin 1 g twice daily when she can afford them, and has started a herbal mixture from a market vendor. She has no chest pain, but her father died of stroke at 60. The clinic has no fundoscope. She says, 'I cannot come every month; I must sell to feed the boy.'
1. What are the priority problems, and how would you distinguish between non-adherence, cost barriers, and a possible adverse effect?
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The priority problems are uncontrolled hypertension with probable target-organ damage, uncontrolled type 2 diabetes with chronic kidney disease, and a high risk of stroke. The dizziness on standing, fatigue and blurred vision need to be explained rather than assumed to be due to high blood pressure alone.
To distinguish the causes:
- Non-adherence: ask non-judgementally how many doses she took in the last 7 days, why doses were missed, and whether she stops when she feels well. Do not accept 'yes, I take it' at face value.
- Cost barrier: ask what she pays per month, whether she has skipped metformin or amlodipine because of money, and whether the herbal mixture is cheaper. Her statement about needing to sell to feed her grandson is a strong clue that cost and time are central.
- Adverse effect: check lying and standing blood pressure; amlodipine can cause ankle swelling and dizziness, but not usually postural hypotension at this dose. Metformin can cause gastrointestinal upset but not blurred vision; hypoglycaemia is possible if she is also taking the herbal mixture or missing meals. The herbal product may contain diuretics, steroids or unknown agents. Blurred vision may be hyperglycaemia or cataract, and she needs an eye examination even though the clinic has no fundoscope.
I would also screen for depression and caregiver strain, because either can mimic fatigue and impair adherence.
2. How would you negotiate a treatment plan that is clinically safe, affordable, and feasible for her?
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I would start by agreeing on what matters to her: staying well enough to trade and care for her grandson, and avoiding a stroke. Then I would simplify rather than simply intensify.
- Blood pressure: aim for below 130/80 mmHg if tolerated. She needs an ACE inhibitor or ARB for albuminuria, but renal function and potassium must be checked within 1–2 weeks because her eGFR is 48. A thiazide-like diuretic may be cheaper than adding another expensive agent. If a once-daily combination tablet is available and affordable, use it.
- Diabetes: continue metformin but review the dose in CKD; 1 g twice daily is acceptable at eGFR 48, but reduce if gastrointestinal symptoms or further renal decline. An SGLT2 inhibitor would be ideal for kidney and cardiovascular protection but may be unaffordable; if so, do not pretend it is equivalent to good adherence and blood pressure control.
- Herbal mixture: ask what it contains and advise stopping it, especially if it may contain steroids or diuretics; explain the interaction risk without shaming her.
- Practicalities: give a 3-month prescription if possible, link her to a nearby pharmacy, and use telephone or community health worker follow-up between visits. Write down the plan in simple language.
The plan must be jointly agreed; a regimen she cannot afford or attend is not safe.
3. What social and mental health issues would you screen for, and how do they change management?
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I would screen for depression, anxiety, grief, financial strain, food insecurity and caregiver burden. Her widowhood, sole care of a grandchild with asthma, missed appointments and statement about needing to sell to feed the boy all raise the possibility of significant psychosocial stress. A simple two-question depression screen followed by a longer tool if positive is practical.
These issues change management in concrete ways:
- If she is depressed, treating it may improve adherence and self-care; cognitive behavioural or problem-solving approaches may be more available than medication.
- If food insecurity is present, hypoglycaemia risk and medicine timing need discussion; metformin may be better tolerated with food.
- If caregiver burden is severe, involve the grandson's asthma care and any extended family or community support; do not simply tell her to attend more often.
- If there is any suggestion of self-neglect or risk to the child, follow local safeguarding procedures.
The clinician should avoid framing this as a failure of willpower. The goal is a realistic shared plan that addresses the conditions she is living with, not only the numbers on the chart.