Inveraray Rural GP, Exams and Management of Hypertension

I don't think I could have been much luckier than being sent to Inveraray for my GP placement! I'm actually living in a B&B in a small village called Furnace about 7 or 8 miles south west of Inveraray. Here's a link to the website. www.maggiesbedandbreakfast.com

My tutor asked me to identify an area of general practice which I wanted to investigate / look into in a bit more detail. When I was looking out for ideas, I found this article in the BMJ this week titled 'Angiotensin converting enzyme inhibitors and angiotensin receptor blockers in hypertension'. The ABCD management of hypertension has changed since I was in first year in 2005 (beta blockers are no longer preferred as a routine first line initial treatment for adults with hypertension), meaning it's now more of the A-CD rule of treating hypertension. I thought that I would take a look at patients with hypertension under the age of 55 and the treatments which they were on. NICE guidelines recommend that white patients <55 years old are started on an ACE inhibitor. The target systolic blood pressure for these patients should be <140mmHg (<130mmHg for patients with higher cardiovascular risk). The guidelines (NICE Clinical Guideline 34) recommend that if the target blood pressure is not achieved, a second agent should be introduced. According the BMJ, 4-30% of long term users of ACE inhibitors have a dry cough and if this is intolerable, an ARB, such as losartan should be introduced. Treatment with an ACE inhibitor and an ARB together was shown to worsen decline in renal function and the two together are contraindicated. So the questions I want to try and answer as agreed with my tutor are:

1. Are there any patients on ACE inhibitors and ARBs?
2. Are patients <55 years old being started on ACE inhibitors?
3. If target BP is not reached, are patient's being offered a second drug?

On another note, I'm spending quite a lot of time at the moment getting my portfolio organised and preparing for my fifth year exams which are looming ever closer. I did however read this blog, and realise that exams are something I'm going to have to deal with beyond medical school! In this post on the BMA website, Ben Molyneux writes that sometimes it seems as if medical recruitment is a merry-go-round of problems and that an average trainee can expect to fail his MRCP exams 1.5 times before passing at an average cost of £2,399! Whats more, there doesn't seem to be agreement between different stages of postgraduate training as to when MRCP exams should ideally be sat. The College suggests that exams be taken during the foundation years, while the Foundation Programme advise that no exams should be taken during the foundation years. Fantastic.