Question: My mother is in her early 60s and has many medical conditions such as interstitial lung disease, diabetes, chronic kidney failure, psoriatic arthritis, and degenerative disc disease. In the last couple of years she has developed sudden intense spikes in her blood pressure accompanied by breathlessness, dizziness, weakness, confusion, shaking, nausea, occasional chest pressure and pain, and occasional pain down her left arm and numbness in her hands. She has been in the ER repeatedly, but she hasn’t had a heart attack and cardiac catheterizations have revealed no blockage in her arteries. The tests for a tumor on her adrenal gland have been inconclusive to normal (possibly due to drug interaction from all of the many medications she is on). Is there any other medical condition that can cause these episodes or is there any other test that can look for the adrenal gland tumor?
Dr. Hibberd's Answer:
Your mother's symptoms can be caused by exacerbations of her existing conditions, that can cause "flash" pulmonary edema, cardiac failure, or arrhythmia (heart rate and or rhythm disturbances) or electrolyte abnormalities. Remember that hypertensive responses are sometimes critical to survival, and while they may reflect an underlying loss of apparent blood pressure regulation, they also may be early warning sings of ischemia (lack of oxygen in tissues), stroke, and myocardial infarction (heart attack).
It is common for a cardiac patient in distress with a heart attack or a stroke patient in the midst of a stroke, to have elevated blood pressure as the body attempts to compensate to the loss of blood supply.
Although your mother's sudden onset may be consistent with other conditions that include adrenal disorders, vasculitis, and other cardiovascular disorders or arrhythmias, the answer to her symptoms is going to be in a careful and meticulous overview of her present health, isolating the trigger that causes her symptoms, and then developing a treatment plan. Her cardiologist, rheumatologist, and endocrinologist should be working in tandem with her primary care physician to isolate the causes of her complaints.
If you still don’t have an answer, request a referral to a local academic center with a medical school affiliation, or consider referral to a specialty center such as The Mayo Clinic, The Cleveland Clinic, or John's Hopkins that take pride in solving puzzles that have eluded local specialists.
A careful, skillful local clinician should be able to search out the cause of her problems. Unfortunately, with managed care, there is significant financial disincentive for meticulous workups. Managed care works fine until you need personalized attention.
Just when you need it most, many are stuck with abbreviated care, poor patient education, and short face-to-face time with their doctors because of the financial constraints managed care has placed on their work. Try billing a managed care company for co-ordination of care and patient education, then compare this reimbursement with a critical care code that involves the same amount of time. One is paid at ten times the rate of the other!
If you really need time with your doctor, and you have a managed care contract, you are generally out of luck, because the insurance contract forbids balance billing or supplemental contracts. If your insurer is the obstacle, change insurance carriers in favor of a plan that permits and pays for unrestricted physician access and consultation.
In my experience, managed care (HMO and restricted physician access plans) works poorly for patients with complex cases, and very well for those who have no need for physician services. If you have a managed care plan in the USA, you often will not have access to some of the largest and most referred medical institutions of the world, regardless of your residence address or financial circumstance, unless of course you pay privately and do not wish insurance re-imbursement!
It seems that we have the highest quality medical care that is sought after world-wide, yet our residents and citizens are generally afforded a tiered system with the top tier being very difficult to access with the modern day health insurance plans. Patients are being fooled with nickel and dime co-pays while declined transplants, laser procedures and chemotherapy if the "health plan" unilaterally decides to deny coverage, or if the patient was not "co-operative" with the insurance plans "regulations" of coverage.
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