A 61-year-old Black male with a history of hypertension presents to your clinic with 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 took his meds […]
A 61-year-old Black male with a history of hypertension presents to your clinic with 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 took his meds this morning.
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...."
Instructions for this assignment:
You may use Medscape or any medical ref textbook (Nurse practitioners) to answer this case.
After assessing the patient’s subjective, objective and diagnostic findings, the main goal of treatment would be to manage his blood pressure effectively. He has presented with a high blood pressure of 190/100 with blurred vision and headaches for four days; in addition, he has been in compliance with his medications. The patient requires immediate emergency care in lowering the blood pressure, as the significant increase can be detrimental. Further investigations to rule out end-organ damage are needed to confirm the diagnosis.
Hypertensive emergency: The patient presented with a high, poorly controlled blood pressure of 190/100 with end-organ damage features, including headache and blurred vision, for three days. According to Suneja and Sanders (2017), hypertensive emergency features suggest impending or progressive organ dysfunction.
Hyperlipidemia: From the laboratory findings, the patient has hypercholesterolemia and hypertriglyceridemia, indicative of dyslipidemia. High LDL and TC are bad cholesterol that contributes to hypertension and atherosclerosis (Karr, 2017).
Other differential diagnosis includes:
Cerebrovascular accident: This could either be ischemic or hemorrhagic. An ischemic cerebrovascular attack may present with headache, blurry vision, and brief loss of consciousness or dizziness as a transient ischemic attack without limb weakness, altered speech, or mouth deviation. When blood pressure is poorly controlled, it can result in ischemic stroke. On the other hand, Hemorrhagic stroke is caused by persistently high blood pressure and can also present with headaches and blurry vision.
The patient will be sent to the ER for hypertensive crisis after probably a dose of clonidine 0.1mg at the clinic. This is because BP is elevated and patient is symptomatic. If patient refuses to go to the hospital then below is the plan of care.
The first care plan would be to review the patient’s records and look for and request the relevant diagnostic and imaging tests needed for this patient. For this patient, the appropriate workup includes an ECG, Chest X-ray, CT scan of the head, Urea and Electrolytes, urinalysis, and cardiac biomarkers (Hu, 2017). These diagnostic tests will provide a diagnosis, determine the prognosis, and guide the course of treatment.
Antihypertensive. Thiazides and calcium channel blockers are the first-line medications for treating hypertension among African Americans. It is also recommended that patients with malignant high blood pressure be brought down slowly over a reasonable period (Suneja & Sanders, 2017). Therefore, I would recommend HCTZ 25mg PO daily and Amlodipine 5mg PO daily for this patient. The patient should also continue with the beta-blocker metoprolol, an antihypertensive, and help lower his pulse rate.
Lipid-lowering agent. The patient has hyperlipidemia; therefore, a lipid-lowering agent like a statin would be handy (Karr, 2017). In this case, I would prescribe Atorvastatin 20mg PO daily at bedtime. Fibrates such as Fenofibrate would also be valuable for this patient.
Anticoagulant. If not addressed, this patient is at risk of developing atherosclerosis and, subsequently, a cardiovascular ischemic complication. I would therefore prescribe Aspirin 81mg PO daily.
Dietary changes. This includes educating the patient about the DASH diet to reduce weight and blood pressure (Hu, 2017).
Regular exercises. Exercises increase the body’s physical activity, cutting fat and lowering blood pressure.
Educate on clinic follow-ups, drug compliance, and adherence. These are critical in ensuring that the patient progresses by following every step of the advised conditions. The Patient is to obtain home BPs and bring the readings to the appointment. Follow-up in the clinic should be in a week’s time, then adjusted depending on BP values. The lipid profile should be redone after three months.
You identify hypertensive emergency as a differential diagnosis for the patient. You point out that since the patient presents with poorly controlled blood pressure, he might have experienced a hypertensive emergency due to end-organ damage. Although the patient presents with elevated blood pressure, he does not demonstrate any significant signs of target organ dysfunction. According to Brathwaite and Reif (2019), hypertensive emergency presents an elevation in blood pressure along with signs of target-organ damage such as pulmonary edema, cardiac ischemia, neurologic deficits, and acute renal failure. The classic manifestations of hypertensive end-organ damage include vascular or hemorrhagic stroke, coronary heart disease, or retinopathy (Suvila et al., 2019, p. 305). Since the patient does not present such symptoms and denies any weakness, numbness, chest pain, shortness of breath, or palpitations, he is not likely to have developed end-organ damage. Therefore, a hypertensive emergency should be ruled out.
References
Brathwaite, L., & Reif, M. (2019). Hypertensive emergencies: a review of common presentations and treatment options. Cardiology clinics, 37(3), 275-286. https://www.cardiology.theclinics.com/article/S0733-8651(19)30029-3/pdf
Hu, D. Y. (2017). New guidelines and evidence for preventing and treating dyslipidemia and atherosclerotic cardiovascular disease in China. Chronic diseases and translational medicine, 3(2), 73.
Karr, S. (2017). Epidemiology and management of hyperlipidemia. The American journal of managed care, 23(9 Suppl), S139-S148.
Suvila, K., McCabe, E. L., Lehtonen, A., Ebinger, J. E., Lima, J. A., Cheng, S., & Niiranen, T. J. (2019). Early onset hypertension is associated with hypertensive end-organ damage already by midlife. Hypertension, 74(2), 305-312. https://www.ahajournals.org/doi/abs/10.1161/HYPERTENSIONAHA.119.13069
Suneja, M., & Sanders, M. L. (2017). Hypertensive emergency. Medical Clinics, 101(3), 465-478.
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