Clinical Case Presentation Saleem Saiyad

Clinical Case Presentation Phong Q. Ong, MD

Clinical Case Presentation  

CC: blurry vision HPI: Patient is a 49 yof with a history of hypertension, CKD and medical noncompliance. On the morning of admission, the patient was seen by her PCP and found to be hypertensive with sbp ~ 240 mm hg. Was sent to ER for further workup. Upon interview in the ER, the patient reported transient blurry vision and headache earlier in the day which had resolved by this time. She otherwise had no complaints.

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PMHx:  

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PSHx: 

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HTN CKD, baseline creat ~2.5 Hysterectomy

Meds:    

Toprol XL 200mg qd Norvasc 10mg po qd Benzapril 20mg po qd HCTZ 25mg po qd

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NKDA Fam Hx: NC Soc Hx: 1ppd tob ROS: as per HPI Labs: 

CBC   

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Wbc: 9.3 Hb: 13.7 Plat: 174

BMP: K+ 2.3, creat 2.8

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EKG:

PE: 259/156 81 98.2 18 Alert and oriented RRR no m/r/g CTAB no r/r/w Soft/nt/nd/nabs No c/c/e No focal neurological deficits 

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ER course: Patient was seen and evaluated in the ER. She was given IV labetalol and given her po meds (Norvasc 10mg, HCTZ 25mg, Toprol XL 200mg). Patient’s bp improved from 259/156 to 117/59. Patient was being prepared for d/c from ER when she was noted to be somewhat confused. General internal medicine called to admit for w/u of AMS.

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ER course cont’d Internal medicine resident at beside to admit patient. Patient now stuporous and lethargic. Patient subsequently sent for stat MRI.

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MRI

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Cardiac enzymes checked and trop elevated to 6.5. Cardiology consulted for further recs. Patient started on ASA/Plavix with plan for cath once acute neurological issues resolved. Neuro/stroke service consulted, 3% NS started, recs to keep map 130-150 with gradual reduction. Patient gradually recovered neurological function and left AMA on hospital day #10.

Hypertensive Encephalopathy 

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Encephalopathy associated with malignant phase of hypertension Cerebral autoregulation: 

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Maintenance of constant cerebral blood flow despite changes in blood pressure. Chronic htn can tolerate higher maps. Increased cerebrovascular resistance, more prone to ischemia.

Hypertensive Encephalopathy 

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Goal 20-25% reduction in map over 1st hour, then gradual titration over next 24 hours based on symptoms Consider short acting, titratable agents No data regarding anticoagulation (per stroke svc, no heparin or IIb/IIIa inh) Cath contraindicated in setting of hypertensive encephalopathy exc. In setting of stemi, cardiogenic shock, VF/VT