Date of Interview and Physical Examination: January 25, 2016

Informant: Patient

General Data:

Patient’s Name: Mrs. M. A.

Age: 56y/o Sex: Female

Address: Balaoan, La union Marital Status: Married

Nationality: Filipino Religion: Roman catholic

Occupation:Housewife Date of Admission: Jan., 2016

# of times admitted: 1

This is the case of Mrs. MA, 56 y/o , female, married, RC, from Balaoan, LU.
Admitted for the first time in this institution.

CHIEF COMPLAINT

Headache and nape pain

HISTORY OF PRESENT ILLNESS

3 days PTA, the patient complained of sudden onset of fronto-temporal headache

associated with dizziness, nape pain with a pain score of 6/10 lasting for 20 minutes.
No vomiting. No loss of consciousness. This happened while patient was doing her
laundry. She took Ibuprofen tablet which provided temporary relief. No consult done.

1 day PTA, patient again had episodes of headache and dizziness which was
spontaneously relieved hence her prevented from doing household chores. No
consult done.

Few hours PTA, the persistence of headache associated with difficulty of breathing
and vomiting 2x and was noted to be restless by her husband. She was brought to
ER immediately, and was eventually admitted.

PAST MEDICAL HISTORY

Medical: No DM or Hypertension.No previous hospitalization due to medical cause.

Surgery: Had uterine tumor removal last 2008 in ITRMC.

Menstrual and Obstetric History: Had menarche at age 14, having regular
menses in 7 days duration. Usually uses adult diaper due to heavy flow during
menstruation also associated with dysmenorrhea. Gravida 3 Para 3( 3003)all
delivered cephalic via normal spontaneous delivery.

Medications:none.

Allergies: No known allergies to food or medications

Psychiatric: None

FAMILY HISTORY

Both parents are alive. His father died of stroke. Her mother claimed to have
hypertension though not taking any maintenance medications. Her uncle in mother
side was also diagnosed to have hypertension. All other siblings are healthy. Her
husband has arthritis with mild physical deficits. All her children appears to be
healthy.

No family history of diabetes, tuberculosis, kidney disease, cancer, anemia, epilepsy,

or mental illness.

PERSONAL AND SOCIAL HISTORY

She worked as a domestic helper in Marikina when she was 15 y/o for 1 year. She
returned to Pangasinan and was married at age 16y/o. Her husband is a retired
soldier and has arthritis and requires assistance when walking. She has 3 children, all
appears to be healthy. Her family is staying in a bungalow type house made of
plywood materials. Uses deep well as a source of water for household purposes and
filtered water for drinking. Disposes garbage in the backyard by burning and
disposes fecal materials by septic tank.

Exercise and Diet:

Eats 3x a day and prefers to eat pork and vegestables. Drinks coffee regularly 1 cup/
day.
Smoking habits:

Patient is a non-smoker.

Alcohol Consumption:

Non-alcoholic

Review of Systems

Constitutional Symptoms: (-)weight loss (-)easy fatigability(-)fever (-)body

weakness(-)body malaise (-)poor appetite

HEENT: (-)dizziness (-)headache (-)tinnitus (-)sore throat (-)throat itchiness (+)

blurring of vision

Respiratory system: (-) cough (-) colds (-)hemoptysis (-) dyspnea

Cardiovascular System: (-)orthopnea (-) PND (+)chest pain (+)easy fatigability

(+) palpitations

Gastrointestinal System: (-)diarrhea (-)constipation (-) melena (-) hematochezia (-)

nausea (-)vomiting (+)abdominal pain

• Genitourinary System: (-)dysuria (-) urinary frequency (-) hypogastric pain (-)
flank pain

• Nervous system: (-)seizure (-) decrease in sensorium (-) LOC (-)right/left

sided weakness

• Musculoskeletal System: (-)muscle pain (-)joint pains (-)joint swelling

• Endocrine system: (-)cold/heat intolerance (-) easy bruisability (-)palpitations

Physical Examination

General Survey

The patient is conscious, oriented to time and place. She is well groomed,
cooperative. Not in any form of pain or distress.

Vital Signs
BP 240/130 mmHg left arm supine. PR 106 bpm regular, bounding pulse .
Respiratory rate 30 cpm. Temperature 36.5 degrees Celsius/ axillary. Ht: 5'2" wt: 67
kg BMI: 27.2 kg/m2

Skin: no pallor, no jaundice, no cyanosis, moist warm skin, good skin turgor

HEENT: pink palpebral conjunctiva, anicteric sclera, no nystagmus, moist lips, moist
oral mucosa,

Chest: SCWE, no retractions, CBS

Heart: AP, tachycardic, PMI at 6th LICS MCL, no murmur, distinct S1 S2.

Abdomen: Flat, NABS, tympanitic, soft, non-tender

Extremities: no palmar pallor, no edema, CRT≤2 sec

Neurologic exam: unremarkable

Initial diagnostic plan

l Flectrocardiogram

2 BUN/creatinine

3 (mnplete blood count

Salient Features:

History

(+) sudden onset of headache associated with dizziness

(+) family history of hypertension

PE

(+) BP: 240/130 mmhg

AP,tachycardic, PMI @ 6th ICS MCL

Impression: Hypertensive crisis

DIFFERENTIAL DIAGNOSIS:

Acute myocardial infarction

lntraparenchymal brain hemorrhage

Subarachnoid hemorrhage

Assessment

The patients most obvious problem on physical examination is a profoundly high

blood pressure.The dyspnea, blurring of vision. dizziness, and headache can all be
due to the high blood pressure.

Often, these complaints an be hard to differentiate from the headache and dizziness
that accompany an intracranial bleed such as a subarachnoid hemorrhage. Further
diagnostic plan

1. Head CT scan

2. Chest x-ray

Treatment plan

Reduction of blood pressure by approximately one-third, but not below a diastolic of

95 mmhg.

Discussion

Hypertensive emergencies encompass a spectrum of clinical presentations in which

uncontrolled blood pressures (BPs) lead to progressive or impending end-organ
dysfunction. In these conditions, the BP should be lowered aggressively over minutes
to hours.

Neurologic end-organ damage due to uncontrolled BP may include hypertensive

encephalopathy, cerebral vascular accident/cerebral infarction, subarachnoid
hemorrhage, and/or intracranial hemorrhage. Cardiovascular end-organ damage may
include myocardial ischemia/infarction, acute left ventricular dysfunction, acute
pulmonary edema, and/or aortic dissection. Other organ systems may also be
affected by uncontrolled hypertension, which may lead to acute renal
failure/insufficiency, retinopathy, eclampsia, or microangiopathic hemolytic anemia.

There are a variety of medications that can be used to treat a hypertensive crisis.
Because of the emergent nature of the crisis and the potential for myocardial
infarction, stroke, and blindness, an intravenous agent that works in minutes is
preferable. The best agents are:

a) Labetalol. This agent works through the nonspecific beta-1 and -2 blockade and is
also a central-acting alpha agent. It has the added advantage of being available
intravenously and orally. There are few serious side effects with emergent use. This
drug can be safely used in oreanancv as well.

b) Nitroprusside. This is both an arterial and venous dilator and has the most rapid
onset of action (seconds) and shortest duration of action (minutes).

c) Nitroglycerin works predominantly through venous dilation. This agent is ideal for
those patients in hypertensive crisis in whom a myocardial infarction may be
occurring.

d) Other agents are enalaprilat (intravenous ACE inhibitor), nicardipine, esmolol,

hydralazine, diawxide, and trimethaphan.

Hypertensive crisis (or “malignant” or “accelerated” hypertension) is not defined on

the basis of any specific blood-pressure number. These terms describe the
development of end organ damage. The most common causes of death from
hypertensive crisis are stroke. renal failure, and congestive heart failure. Other
manifestations of the syndrome include retinal changes (such as in this patient) and
confusion from altered cerebral blood flow. The electrocardiogram abnormalities are
the findings consistent with left ventricular hypertrophy (SV2 + RV5 > 35 mm). ST
segment depression can also result from hypertrophic cardiomyopathy.

Case Review

Subarachnoid Hemorrhage

- Spontaneous rupture of an aneurysm in the circle of Willis

- Fever, headache, and nuchal rigidity can make it look like meningitis
- More sudden onset than meningitis and can result in a loss of consciousness

- Head CT is 90-95% sensitive on the first day and eliminates the need tor lumbar
puncture lumbar puncture is not dangerous: you can have increased white blood
cells in the cerebral spinal fluid just from the blood

- Control blood pressure, give mmodipine. and find the souroe ot bleeding with an
angiogram

Migraine Headache

-May give fever, photophobia, and rarely, a still neck

- Doesn't give a loss of consciousness or lever

- Head Ct and lumbar puncture are normal

lntraparenchymal Bleeding

- No neck stiffness or photophobia

- Often with signs of mass effect similar to those of a tumor but much more rapid in
onset

- Easily seen by contrast negative CT sen; do not use contrast when looking tor
blood

Hypertensive Emergency

Severe Hypertension where BP is > 180/110 mmHg with evidence of target organ
damage.

1.Retinopathy / Retinal hemorrhage

2.Encephalopathy/I.C hemorrhage/ IC tension

3.Acute Pulm. Oedema, Myocardial ischaemia/Aortic dissection.

4. Acute Renal Failure

Approximately 25% of emergency room visits are due to hypertensive crisis.

BP > 180/110 mmHg

Emergency : Target organ damage.

Urgency : No target organ damage.

Common precipitating Factors:

1. No regular health checks

2. Age - elderly

3.Sub therapeutic treatment

4. Non adherence to medication.

5. Lack of family care physician.

Urgency : Out-patient

Oral medication

BP reduction 24-48 hours

Emergency : Inpatient

Intravenous

Immediate BP reduction < 25% within minutes – 1 Hour

160/100 : 2-6 hoursManagement: ( Basic Principle)