Mr. T, a white man aged 51 years, presented to a free clinic for management of hypertension and to obtain prescriptions. Although he had insurance through the U.S. Department of Veterans Affairs (VA), Mr. T stated that he felt safer coming to the free clinic.

Mr. T had previously obtained medications through a variety of free clinics but was looking for a location where he could receive regular care. With a history of homelessness, substance abuse and mental illness, Mr. T thought the free clinic would be a good solution. He reported no other comorbidities, family history or past medical issues. He stated that his hypertension was well managed with a 
two-drug regimen.

After several visits, the clinic staff members noted that Mr. T’s pulse and BP fluctuated drastically. He was on a beta blocker to manage hypertension, but he also reported consuming at least two pots of coffee per day. Additionally, Mr. T stated that he had increased anxiety when he came to the clinic because there he would see people with whom he had previously used drugs. 

Mr. T routinely refused laboratory evaluation and would not return for follow-up appointments with any regularity. Given his nonadherence 
to medication and follow-up, the providers began to question other causes of his tachycardia and hypertension, notably extreme anxiety and possibly substance use.

1. History

Mr. T’s history indicated polysubstance abuse and increased anxiety, with self-diagnosed 
panic attacks that occurred weekly. Mr. T reported attending Narcotics Anonymous meetings several times per week. He noted previous attempts to cut down his caffeine consumption but found that his anxiety continued.

Mr. T was previously homeless but was working in sales at the time of his appointment. He reported no current use of alcohol or illicit drugs but admitted to smoking one to three 
packs of cigarettes a day, depending on his anxiety level. 

Mr. T also 
reported taking metoprolol (Lopressor, Toprol) 50 mg b.i.d. and hydrochlorothiazide 25 mg once daily for treatment of hypertension. 

2. Examination

On presentation, Mr. T appeared anxious. His speech 
was rapid, he displayed minimal eye contact during consultation, and he tapped his feet throughout the visit. 

The patient’s BP was mildly hypertensive (145/82 mm Hg), and his pulse was 68 beats per minute. Mr. T’s BMI was 20.87. 

Head and neck exam were unremarkable, lung sounds were clear, and heart rhythm was regular without extra sounds. An abdominal exam was also unremarkable with normoactive bowel sounds. No peripheral edema was noted. 

3. Laboratory Data and Diagnosis

After a lengthy discussion, the patient agreed to venipuncture. Given Mr. T’s history of polysubstance abuse, and his anxiety symptoms, the providers doubted he would return for additional testing. Thus, a battery of tests were ordered, including a lipid panel, hemoglobin A1c, a complete blood count and comprehensive metabolic panel, and several thyroid tests (triiodothyronine [T3], thyroxine [T4], and thyroid-stimulating hormone [TSH]).

This article originally appeared on Clinical Advisor