Case Presentation

SANCHEZ, Julienne Rowelie A.

AUP Clinical Clerk ‘19
General Objectives:
To present the case of a patient suffering from
Hypertensive Urgency
 
Specific Objectives:
 To define hypertension
 To differentiate between hypertensive urgency
and emergency
 To determine the appropriate diagnostics and
management of hypertension
Demographics
• E.A.B
• 54 year old Female
• Filipino
• Widow
• SDA
• Born on January 4, 1965
• Carlos, Pandacan, Manila
• First time to seek consult in our
institution – March 23, 2019
 Dizziness

Chief Complaint
History of Present Illness
Few hours PTA

• Dizziness- Non-rotatory, consistent

• (+) Nausea, (-) Vomiting episodes
• No headache, nape pain, chest
Consult
• Patient was apparently well. pain, slurring of speech, blurring of
vision, loss of consciousness, body
weakness
• BP: 200/120
• Took Losartan 50mg
• No relief
(+) HTN x 15 years – Losartan 50mg at AM
Non-compliant; HBP: 140/90, UBP: 120/80 (+) Hypertension - Father
Place Your Picture Here
No DM, Heart Disease, Asthma, PTB, COPD, No known family history of Heart Diseases,
Cancer Asthma, Pulmonary Tuberculosis, Thyroids
No known allergies to food and drugs. disease, Stroke and Renal Diseases.
No previous hospitalizations
and surgeries.

Housewife, currently living with children

Widowed
LMP: Menopause
No food preference, no diet restrictions
G4P2(2022) via CS (+) Occasional alcoholic beverage
drinker
Non-smoker
 (-) Weight change, Fatigue,
Easy fatigability, Chills, Loss of
Appetite
(-) hematemesis, no dysphagia,
no heartburn, no abdominal
pain, no change in bowel
(-) Rashes, pruritus, habits, no diarrhea, no
discoloration constipation, no melena, no
hematochezia

(-) discharges, no pruritus, no

(-) headache, vision changes, dysuria, no frequency
dysphagia, colds

(-) seizures, no loss of

(-) cough, DOB, Hemoptysis consciousness, no change of
behavior, no body weakness.

(-) Chest pain, palpitations

PHYSICAL
Patient is awake, conscious,
EXAMINATION coherent, ambulatory, and not in
GENERAL SURVEY
cardiorespiratory distress.

She is of average body built and

height, well groomed.
PHYSICAL
Vital signs
EXAMINATION BP: 140/90 HR: 63 bpm RR: 16 cpm
VITAL SIGNS
T: 36. 1 C O2 sat: 98%

Height: 160 cm Wt: 51.7 kg

BMI: 20.19 kg/m2
PHYSICAL
EXAMINATION
SKIN No pallor, no cyanosis, no
rashes, no lesions, good skin
turgor
 Head - Skull is normocephalic. Hair
PHYSICAL distribution normal and with average
texture.
EXAMINATION Eyes - Anicteric sclerae, pink palpebral
HEENT conjunctiva. No conjunctival injections;
Ears – bilaterally symmetrical, non-tender,
no lesions, no foul smelling, no discharges.
Throat – moist oral mucaosa, pinkish
pharynx without exudates and non-
enlarged tonsils with good dentition.
Tongue midline.
PHYSICAL
EXAMINATION No visible neck masses, non-
NECK
distended neck veins, Supple, no
cervical lymphadenopathies No
palpable masses
 No lesions, symmetrical chest
PHYSICAL expansion, good inspiratory effort,
tactile fremitus present and
EXAMINATION bilaterally equal.
CHEST/ LUNGS
Lungs are resonant upon percussion
on all lung fields.

Breath sounds vesicular; no rales,

crackles, wheezes or rhonchi. No
adventitious breath sounds.
PHYSICAL No deformities, adynamic
precordium, No heaves, thrills, and
EXAMINATION lifts noted. PMI best at 5th
HEART
intercostal space, midclavicular line.
Normal rate with regular rhythm. At
the base, S2 is greater than S1. At the
apex, S1 is greater than S2.
No murmurs.
PHYSICAL
Flabby, nondistended, normoactive
EXAMINATION bowel sounds, tympanitic on all
ABDOMEN
quadrants, Soft without direct and
rebound tenderness, no palpable
masses and organomegaly noted.
No CVA tenderness.
PHYSICAL
EXAMINATION No edema, no clubbing of the digits,
MUSCULOSKELETAL &
EXTREMITIES full and equal pulses, Capillary Refill
<2 seconds. Full range of motions in
all extremities.
 Salient Features

 54 year old Female

 Diagnosed Hypertensive 15 years PTA
 Was prescribed with Losartan 50mg OD- Noncompliant.
 Non-rotatory dizziness
 Nausea
 BP 200/120
Your Picture Here

Differential Diagnosis of
Dizziness
 BPPV
Your Picture Here RULE IN RULE OUT
(+) Dizziness (-) Vertigo, precipitated by rapid
Age – 54 years old change of head positions or
(+) Nausea posture(turn from side-side);
(-) Wax-wane pattern.
(-) Torsional nystagmus
(-) Confirmed by Dix-Hallpike
test
Hypertensive Emergency
RULE IN RULE OUT
(+) BP: 200/120 (-) headache, nape pain, chest
(+) Nausea pain, slurring of speech, blurring
(+) Noncompliant to of vision, loss of consciousness,
medications body weakness, dysuria, oliguria

Hypertensive Urgency
RULE IN RULE OUT
(+) BP: 200/120 Cannot totally rule out
(+) Nausea
(+) Noncompliant to
medications
Hypertensive urgency
ADMITTING DIAGNOSIS
 Admitting Orders
• Admit under the service of Dr. Varona
• Secure consent to care and management
• VS q4, I & O q shift
• Diet: Low salt, Low fat
• IVF: PNSS 1L x 80 cc/hr
• Diagnostics:
CBC, Na, K, LP, FBS, Crea, ALT, Trop I, CBG
CXR PA/L, CG 12L, UA, BUA
• Therapeutics:
1. Losartan 50mg/tab, 1 tab OD
2. Esomeprazole 40mg IV OD Pre-meals
3. Betahistine 16mg/tab, 1 tab TID
• Dr. Varona updated
• Refer accordingly
Diagnostics
CBC
Hgb 131
Hct 0.41 Trop I 0.010
WBC 6.10
Segmenters 72
Lymphocytes 19
Platelets 276

UA
SGPT 20 SG 1.010
Creatinine 65 pH 7
BUA 315 wbc 0
Na 142 rbc 1
K 4 Bacteria 119
MT 3
Hypertensive Urgency
 Hypertension
• Blood pressure of 130/90
• Based on an average of a 2
careful readings obtained on
>2/= occasions

2017 ACC/AHA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults
 Epidemiology

• According to the latest WHO data published in 2017

Hypertension Deaths in Philippines reached 14,751 or
2.38% of total deaths.
• 8th leading. cause of death in the Ph
• Ph ranks 44th in the world

2017 WHO
 Epidemiology

• Early Adulthood- Men

• 60 years and older- Women
• Diastolic blood pressure increases progressively with age
until ∼55 years, after which it tends to decrease

pp. 1611, Harrison’s Principles of Internal Medicine 19th edition

 Risk Factors

• Obesity and weight gain

• High NaCl intake
• Low dietary intakes of calcium and potassium
• Alcohol consumption
• Psychosocial stress
• Low levels of physical activity

pp. 1612, Harrison’s Principles of Internal Medicine 19th edition

 Mechanisms of Hypertension

• Intravascular Volume
• Autonomic Nervous System
• RAAS
• Vascular mechanisms

Harrison’s Principles of Internal Medicine 19th edition, pp 1612

Intravascular Volume
Autonomic Nervous System
Vascular mechanisms
Categories of Hypertension

2017 ACC/AHA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults
 Clinical Disorders of Hypertension

• Primary “Essential” Hypertension

• Secondary Hypertension

Harrison’s Principles of Internal Medicine 19th edition, pp

Harrison’s Principles of Internal Medicine 19th edition, pp
Screening

2017 ACC/AHA Guideline for the Prevention, Detection,

Evaluation, and Management of High Blood Pressure in Adults
Screening

2017 ACC/AHA Guideline for the Prevention, Detection,

Evaluation, and Management of High Blood Pressure in Adults
 Screening

2017 ACC/AHA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults
 Diagnostics

2017 ACC/AHA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults
 Management

2017 ACC/AHA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults
 2017 ACC/AHA Guideline for the Prevention, Detection,
Evaluation, and Management of High Blood Pressure in Adults
 Hypertensive
Urgency vs.
Emergency

2017 ACC/AHA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults
2017 ACC/AHA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults
2017 ACC/AHA Guideline for the Prevention, Detection,
Evaluation, and Management of High Blood Pressure in
Adults
2017 ACC/AHA Guideline for
the Prevention, Detection,
Evaluation, and
Management of High Blood
Pressure in Adults
2017 ACC/AHA Guideline for
the Prevention, Detection,
Evaluation, and
Management of High Blood
Pressure in Adults
 Resources:

2017 ACC/AHA Guideline for the Prevention, Detection,

Evaluation, and Management of High Blood Pressure in Adults

Harrison’s Principles of Internal Medicine 19th edition, pp 1612

2017, Hypertension update, JNC8 and beyond;

Current Opinion in Pharmacology
Thank you!