GENERAL DATA & PATIENT’S PROFILE:

This is the case of patient EA, 46 year old Male, Married, Filipino, Roman Catholic, currently residing in Capas, Tarlac and was admitted for first time in Tarlac
Provincal Hospital.

CHIEF COMPLAINT: DIZZINESS

HISTORY OF PRESENT ILLNESS:

Patient is a known case of hypertension stage II since 2018, compliant with anti hypertensive medications.

Few hours prior to admission, patient experienced headache (sharp, 6/10) and dizziness. No other associated signs and symptoms like fever, vomiting, blurring of
vision, disorientation and loss of consciousness. He was bought to TPH ER and found to be hypertensive. Despite having Captopril 25mg tab sublingually three times in 15
minutes interval, his blood pressure was elevated. He was advised for admission. Hence admitted.

PAST MEDICAL HISTORY:

(+) Hypertension: Losartan 50mg tab OD, Amlodipine 10mg tab OD HS

(-) Diabetes (-) Asthma

(-) PTB (-) Previous surgery

FAMILY MEDICAL HISTORY:

(+) Hypertension: Mother

(-) Diabetes (-) Asthma (-) PTB (-) Previous surgery

ENVIRONMENTAL AND SOCIAL HISTORY:

Patient is a factory worker and father of 4 sons and 1 daughter. Patient lives in one story concrete house with 3 bedrooms, each of which has one window. They
drink refill jar water. Garbage is collected and given to garbage trucks. No organophosphate exposure history. No past history of travel.

ALCOHOL: Quit on 2019, before was a regular drinker (1 bottle of emperador a day)

SMOKING: 20 pack years

DRUG ALLERGIES: NONE

OTHER ALLERGIES: NONE

DRUG THERAPY: NONE

REVIEW OF SYSTEMS:

General survey: (+) weakness, (-) weight loss/gain

Integumentary: (-) rashes, (-) dryness, (-) itchiness

Head and Neck: (+) headache, (-) trauma, (-) discharge, (+) weakness

Eyes: (-) redness, (-) discharge

Ears: (-) discharge, (-) hearing loss

Nose: (-) colds, (-) discharge, (-) epistaxis

Mouth and Throat: (-) ulceration

Respiratory: (-) cough, (-) phelgm, (-) dyspnea, (-) hemoptysis

Cardiac: (-) chest pain, (-) cyanosis

GIT: (-) nausea, (-) vomiting, (-) abdominal pain, (-) constipation
GUT: (-) hematuria, (-) dysuria, (-) diaper rash

CNS: (-) tremor, (-) incordination, (-) paralysis

Musculoskeletal: (-) myalgia, (-) arthralgia

Endocrine: (-) excessive sweating

Hematologic: (-) easy bruising

PHYSICAL EXAMINATION:

General survey: Awake, alert, conscious, coherent

BP: 200/130 CR: 112 RR: 24 TEMP: 36.7 C

Skin: (-) pale, (-) pallor, good skin turgor

HEENT: Normocephalic, (-) lumps, anicteric sclera, pink palpebral conjunctiva, (-) nasoaural discharge, (-) tonsilopharyngeal congestion

Chest and Lungs: symmetrical chest expansion, (-) retractions, Clear breath sounds, (-) mass, (-) chest lag

Cardiovascular: Adynamic precordium, tachycardic, (-) murmur

Abdomen: Flabby, tympanitic, normoactive bowel sounds, soft, non-tender in all quadrants

Rectum/Genitalia: (-) lesion, (-) mass, grossly male, (-) DRE

Extremities: (-) edema, good and equal pulses

NEUROLOGICAL EXAMINATION:

Cerebrum: Awake and Conscious

Cerebellum: (-) tremor, (-) nystgamus

Cerebrum: awake and conscious

Cerebellum: (-) tremor, (-) nystgamus GCS: 15 (M6V5E4)

CN I: can smell on both nostrits (-) Neck rigidity (-) Kernig’s

(-) Babinski’s (-) Brudzinski’s

CN II: pupils reactive to light and accomodation

CN III, IV, VI: intact extraocular movement

CN V: (+) corneal reflex

CN VII: facial symmetry

CN VIII: can hear on both ears

CN IX,X: (+) gag reflex, uvula midline

CN XI: (+) shrug shoulder

CN XII: (-) tongue deviation

DIFFERENTIAL DIAGNOSIS
Hypertensive Urgency Vs Hypertensive Emergency

HYPERTENSIVE URGENCY:

RULE IN RULE OUT

• elevated SBP of >180 mmHg • shortness of breath
DBP of > 120 • Epistaxis
mmHg
• headache

HYPERTENSIVE EMERGENCY:

RULE IN RULE OUT

• elevated BP • negative for end organ
damage such as:
• chest pain
• shortness of breath
• nausea and vomiting
 • severe back pain
• numbness
• slurred speech
• No new onset hemiparesis

ADMITTING DIAGNOSIS-HYPERTENSIVE URGENCY

 CASE DISCUSSION

DEFINITION:
Defined as any one of the ffg:
SBP >= 140mmHg
DBP >= 90mmHg
taking antihypertensive medications

EPIDEMIOLOGY
Although ,approximately 16.4 % of the FILIPINOS have hypertension.

 Nearly 75% of these population are aware of the problem.Nearly 65 % of them are getting treatment. And nearly 23% are compliant to
medicine and have acceptable blood pressure control, only 1% develop hypertensive crisis.The typical patient who presents with a
hypertensive crisis is 40–50 years of age,MALE noncompliant with hypertensive therapy, lacks primary care, and uses illicit substances
and/or alcohol.,oorly controlled essential hypertension (MOST COMMON)

 Hypertension is one of the leading causes of the global burden disease with 7.6m deaths, 92million disability adjusted life years. 2x risk of CVD,
CHF, Renal failure, PAD

 some clues for suspecting hypertension :

-abrupt onset of hpn or excerabation of previously controlled hpn
-age of onset <20 or >50 y/o
-no family history of hpn
-DBP >110-120 mmHg
-sudden inc in BP in a patient w/ stable stage I hpn
 RISK FACTORS:
Gender
Age
CLASSIFICATION OF HYPERTENSION:

Primary/ Essential Hypertension Secondary Hypertension

• 80-95% • 5-20%
• Familial • results from an identifiable
• Consequence of interaction causes for eg, kidney
between environmental and disease, renovascular
genetic factors disease, endocrine diseases,
• Prevalence increases with mechanical compression,
age obesity and sleep apnea

MOST COMMON CAUSES:

-Rapid unexplained rise in BP in pt with chronic essential HPT
-most have history of poor treatment/compliance or an abrupt discontinuation of their meds
Other causes:
-Renal parenchymal disease (80% of sec.causes)
-Systemic disorders with renal involvement (SLE)
-Renovascular disease (Atheroscleroses/fibromuscular dysplasia)
-Endocrine ( phaeochromocytoma/cushing syndrome)
-Drugs (cocaine/amphetam/clonidine withdrawal/diet pills)
-CNS (trauma or spinal cord disorders – Guillain-Barre
-Coarctation of the aorta

REVISED BLOOD PRESSURE CATEGORY

HYPERTENSIVE CRISIS:

DEFINITION:
Refers to number of clinical circumstances that requires prompt reduction of BP.
Includes :
Hypertensive Emergency and
Hypertensive Urgency

Hypertensive Emergency vs Urgency

HYPERTENSIVE HYPERTENSIVE
URGENCY

EMERGENCY
SBP >180 mmHg SBP >180
BLOOD PRESSURE and mmHg and
DBP >120 mmHg DBP >120
( requires mmHg
immediate but ( can be slowly
controlled treated)
reduction of BP
TARGET ORGAN NONE PRESENT
 DAMAGE

BACKGROUND DEFINITIONS

Hypertensive crisis : It is a clinical syndrome that is associated abrupt, marked increase in blood pressure “relative to the patient's baseline” causes acute
or rapidly progressing end-organ damage.
v
It includes
1) Hypertensive urgencies: sever BP elevation without acute TOD.
2) Hypertensive emergencies: defined as severe elevation in BP(>180/120mmHG)associated with evidence of new or worsening target organ
damage( acute TOD).

Examples of impending end-organ damage include

• papilledema,

• shortness of breath,

• and pedal edema.