A Gallon a Day Keeps the Doctor Away: the Importance of Patient Education in Hypertension and Gout Management

Abstract: This case study delves into the life of a 33 year old male with a long history of hypertension and gout, inconsistent medication use, lapses in medical care, and a series of unrecommended diet and exercise routine choices. These conditions can be managed through diet and exercise changes, as well as the cessation of cigar smoking. The purpose of this case study is to emphasize the value of interventions to slow the progression of his existing conditions, and education to prevent the development of new conditions.

Introduction: Hypertension and gout are two chronic conditions that are heavily influenced by the patient’s lifestyle choices. Gout is a painful deposition of urate crystals in joints and tissues in response to an inflammatory event. Hypertension is, in essence, defined by elevated blood pressure which can increase risk of cardiovascular, kidney, and vascular diseases.

Case presentation: The patient is a 33 year old male with a current history of hypertension and gout presents seeking reestablishment of care and refills of medications. The patient reports he has not had a regular primary care provider for 15 years. The patient reports he has been managing his hypertension and gout by visiting urgent care centers to refill his medications. He reports the last gout flare-up was 6 months ago after a heavy meal, which was treated with corticosteroids obtained from an urgent care center with a return to baseline.

The patient is prescribed hydrochlorothiazide 25 mg daily, diltiazem 120mg daily, and allopurinol 100 mg daily, but reports noncompliance due to cost. The patient reports he is an occasional alcohol drinker and smokes approximately 4 cigars a week. He lives with his girlfriend and child in a third-floor walk-up apartment building.  The patient admits he can climb stairs without difficulty except during a gout flare-up or when carrying things into the apartment.

Vital signs obtained in office are as follows: Blood pressure: 140/88, pulse: 72bpm, respiration rate 18, temperature 98.6ºF, height 5’10”, weight: 200lbs, waist circumference 43 inches.

Dietary issues that the patient has disclosed includes his high intake of fats by drinking a gallon of full-fat milk a day, as well as a high purine diet consisting of meat and sugary beverages and snacks. This diet contributes heavily to his “beer belly,” as well as his gout flare-ups. The patient can transition to low-fat or skim milk, replace pastries and snacks with healthier alternatives, and increase his intake of water, fruits, and vegetables. The patient can consider replacing sugary beverages with zero-sugar options in order to increase compliance. He may also consider avoiding high-purine foods to avoid gout flare-ups.

The patient endorses no regular exercise, but will transition to a relatively active job. The patient can incorporate activities he reports enjoying, such as casual basketball or outdoor walks, to slowly reach the recommended 150 minutes of exercise per week. By starting slowly, and increasing duration as he feels comfortable, he may reduce his fatigue and shortness of breath after climbing the stairs in his apartment building.

Cigar smoking may also be contributing to the patient’s hypertension, as nicotine and tobacco use can cause atherosclerosis. Once he establishes care, education can be provided to him about quitting or reducing cigar use in order to lower his blood pressure. In addition, the patient’s gout may be exacerbated by the use of a thiazide diuretic like hydrochlorothiazide. The patient can be switched to a medication like an ACE inhibitor, ARB, or the dosage of Diltiazem can be increased to mitigate that as per the JNC 8 guidelines.

Because the patient is seeking re-establishment of care after 15 years, the USPSTF recommends the patient receives: influenza vaccine, Tdap, HIV testing, STI screening, Hepatitis C screening, cholesterol/lipid panel, and depression screening.

Discussion: Factors that influenced his lifestyle were socioeconomic elements like decreased access to care, low income, and a lack of time due to family and career. The absence of guidance from an established healthcare provider fueled the patient’s decision making based on what he thought was “right.” While there is no real “right” answer, there are modifications the patient can make to his lifestyle that would manage his symptoms and improve his life quality in accordance with his goals. Clinicians can view his case to recognize the impact simple patient education can prevent the development of lifelong, uncontrolled, preventable diseases in young patients. By creating a plan that is realistic but effective, the patient will be likely to adhere to the plan and mitigate his risks.

Conclusion: The diagnoses of hypertension and gout in this 33 year old male patient  can all be attributed to the choices the patient made without the guidance or motivation of a healthcare professional due to his lapses in insurance. Access to healthcare with diet and exercise changes can manage his symptoms and change the trajectory of his career, family life, and wellbeing.

References

UpToDate. (2025). Uptodate.com. https://www.uptodate.com/contents/gout-nonpharmacologic-strategies-for-prevention-and-treatment?topicRef=145937&source=bqp

Armstrong, Carrie. “JNC 8 Guidelines for the Management of Hypertension in Adults.” American Family Physician, vol. 90, no. 7, 2014, pp. 503–504, www.aafp.org/pubs/afp/issues/2014/1001/p503.html.

Handler, Joel. “Managing Hypertensive Patients with Gout Who Take Thiazide.” The Journal of Clinical Hypertension, vol. 12, no. 9, 8 July 2010, pp. 731–735, https://doi.org/10.1111/j.1751-7176.2010.00346.x.

USPSTF. “Screening Recommendations.” U.S. Preventive Services Task Force, 2025, www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations.

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