A 20-year-old woman presents to urgent care with headache and palpitations for 1 day. She describes a throbbing frontal headache associated with intermittent dizziness and a sensation of a racing heart. She denies chest pain, shortness of breath, visual changes, or focal neurologic symptoms. Her past medical history includes obesity and migraine headaches. Her BMI is 32.9. She denies a history of hypertension. She reports taking sumatriptan occasionally for migraines, and she recently started a daily weight-loss pill obtained from a telehealth weight-loss clinic approximately 2 weeks ago. After checking her phone, she confirms the medication is phentermine.
Her vital signs are: temperature, 98.4°F; heart rate, 112 beats/min; blood pressure, 168/96 mm Hg; respiratory rate, 16 breaths/min; and oxygen saturation, 99% on room air. On physical examination, she appears anxious but in no acute distress. Cardiac examination using electrocardiogram reveals sinus tachycardia with a regular rhythm. Lung sounds are clear. Neurologic examination is normal.
After symptomatic treatment, what is the most appropriate initial management of this patient?
- Treat with a beta-blocker but allow her to continue taking the phentermine.
- Refer the patient to the emergency department to obtain emergent head computed tomography.
- Discontinue phentermine and monitor for improvement.
- Initiate intravenous antihypertensive therapy.
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Correct answer: c. Discontinue phentermine and monitor for improvement.
Phentermine is a sympathomimetic stimulant that can cause tachycardia and hypertension. Management involves discontinuing the medication and providing supportive care, with monitoring for improvement. The patient received oral acetaminophen for her headache and rested in the clinic for an hour for observation. Her vital signs were repeated and show that her blood pressure is 148/88 mm Hg and heart rate is 96 beats/min. Her symptoms improved.
Prior to discharge, the patient was advised to stop taking phentermine, as it can cause headaches, palpitations, or elevated blood pressure. Given the patient’s BMI and voiced frustrations with losing weight, you counseled the patient about talking to her primary care doctor regarding a weight-loss plan that includes a prescription for a commercially available weight-loss medication, along with appropriate medical supervision.
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Tracey Davidoff, MD, FACP, FCUCM, has practiced Urgent Care Medicine for more than 15 years. She is Board Certified in Internal Medicine. Dr. Davidoff is a member of the Board of Directors of the Urgent Care Association and serves as Co-Editor-in-Chief of the College of Urgent Care Medicine’s “Urgent Caring” publication. She is also the Vice President of the Southeast Regional Urgent Care Association and a member of the editorial board of the Journal of Urgent Care Medicine. At EB Medicine, Dr Davidoff is Editor-In-Chief of Evidence-Based Urgent Care, and co-host of the Urgentology podcast.
