Mary is a lovely 56-year old Haitian woman who comes to the shelter clinic for a blood pressure check. I have not seen her since December, but she is well known to me and Dr. Means, as she frequents the clinic, sometimes just to say hi and other times for her weekly supply of calcium+vitamin D. Today, her blood pressure is 125/80, which is quite low for her. She beams and says, “Doctor, I remember you told me stress can give high blood pressure.” Apparently, it is her New Year’s resolution to try to reduce her stress level, and she points to her blood pressure level today as evidence.
As she tells me about her several crochet projects, she brings up new complaints of “leg swelling” and “chest cramping” since the last time I saw her. I elicit more information. She describes the chest discomfort as a dull/cramping and localized to her right chest but without radiation or additional symptoms of chest pain, dizziness, light-headedness, sweating, or nausea. It occurs approximately once every 2-3 weeks and is unrelated to physical activity or meals. Most episodes, including the one last night, came on while at rest, and are relieved by drinking warm water.
On exam, Mary is a well-nourished, slightly-obese woman. Her lungs are clear and her heart has a regular rate and rhythm and is without murmurs. Palpation of her chest does not elicit pain, which might indicate a musculoskeletal cause of her chest cramping. Her abdomen is soft and non-tender. On examination of her extremities, she has slight 1+ edema (swelling) of her lower extremities bilaterally, but no skin changes or other abnormalities. Normally, leg swelling can be a sign of heart disease and reduced capability of the heart to pump blood forward, but especially in a woman such as Mary who spends most of her day on her feet, edema can be a much less specific sign of heart failure.
Reassured that Mary’s complaints do not represent an imminent medical issue, I focus on some medical education and cardiovascular prevention. While Mary’s blood pressure was within the normal range today, she regularly has blood pressures in the high 130s/90s, which places her in the pre-hypertension range. In fact, she has several risk factors for hypertension and heart disease including her weight, age, and post-menopausal status. Furthermore, she is not aware of whether she has high cholesterol, but I have high suspicion that she does given the candy bars she stores in her handbag.
Knowing Mary, I have faith that she truly wants to improve her health. However, barriers such as culture and medical insight prevent her from doing so in the most effective way. For example, when asked her how her diet is, Mary responded with “Oh, I eat very well!” indicating that she has a good appetite. This was a nice moment to introduce portion control and emphasize the importance of fruits and vegetables as well as reduced salt and cholesterol intake. Her pride in reducing her stress as the cause of high blood pressure demonstrates another slightly misguided understanding of blood pressure. While praising her efforts to reduce her stress and lower her blood pressure, I directed our conversation back towards increasing exercise and reducing alcohol intake.
My interactions with Mary have illustrated to me the intricacies of medical prevention with women like her. Many truly want to improve their health, and are able to with some education and a nudge in the right direction…
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