Patient Portrays Malignant Hypertension Discussion
Patient Portrays Malignant Hypertension Discussion
A 61-year-old Black male with a history of hypertension presents to your clinic for complaints of headaches and blurred vision x 4 days. He denies any weakness, numbness, chest pain, shortness of breath, palpitations, or recent, illicit drug use. He states he has been compliant with his medications (hydrochlorothiazide and metoprolol), and he took his meds this morning.
His V/S include: B/P 190/100, P- 90, T- 98.9, R- 22. Recent labs show that TC- 260, LDL-190, HDL- 35, Trig- 320. He did not return for these results and did not start any new meds.
What are your diagnoses and plan of care for this patient. Remember to include your rationales.
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I would first perform a physical exam for this patient. I would want to perform a cardiac and pulmonary exam as well as an eye exam. During the eye exam I would be looking for bilateral retina changes including papilledema, hemorrhages, cotton wool spots and exudates. Considering the patients blood pressure is elevated and he has symptoms of headache and blurred vision I would diagnose him with hypertensive urgency/malignant hypertension if there were positive findings during the eye exam. In this case he would need to go to the emergency room where I would recommend the diagnostic tests CBC, CMP (to check kidney function), Troponin and CRP (to check for myocardial ischemia), UA (to check for proteinuria and/or hematuria), chest X-ray (check for cardiomegaly, pulmonary edema) and ECG. (Qaseem et al. 2017).
I would anticipate him receiving either a Nicardepine infusion at 5mg/hr with a max dose of 15mg/hr or IV Labetolol 20mg q 10 minutes until desired response is achieved with a max dose of 300mg. This could also be given as an infusion at 0.5-2mg/min. (Suneja et al. 2017)
If the patient does not display any retinal changes indicating malignant hypertension, or upon discharge from hospital, I would anticipate him having a change in medications.
I10 Essential Hypertension Vs. I16.0 Hypertensive Urgency
Amlodipine 2.5 to 10mg daily
Chlorthalidone 12.5 to 25mg daily (higher potency and longer half-life in comparison to hydrochlorothiazide) (Qaseem et al. 2017)
“Thiazide diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and calcium channel blockers are the preferred medications in non-african american patients; thiazide diuretics and calcium channel blockers are preferred in African American patients.” (Langan et al. 2016)
Diet consisting of whole grains, fruits, poultry, vegetables and limited sugar intake. Exercise at least 30 minutes a day.
E78.00 Hypercholestolemia
Atorvastatin 40-80mg daily
Low trans and sat fat diet. Exercise (USPST. 2016)
References
Final Recommendation Statement: Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: Preventive Medication: United States Preventive Services Taskforce. Final Recommendation
Statement: Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: Preventive Medication | United States Preventive Services Taskforce. (2016, November 13).
Langan, R. C., & Jones, K. (2016, June 1). Common Questions About the Initial Management of Hypertension. American Family Physician. https://www.aafp.org/afp/2015/0201/p172.html.
Suneja M, Sanders ML. Hypertensive emergency. Med Clin North Am. 2017
Qaseem A, Wilt TJ, Rich R, et al. Pharmacologic treatment of hypertension in adults aged 60 years or older to higher versus lower blood pressure targets: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med. 2017
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