ARGHWINGS KODHEK ROAD
NAIROBI, 020-2845000
hosp@nbihosp.org
Patient's Name: TERRY MUTUA
Date of Admission: 13-08-2023
Date of Discharge: 15-08-2023
Medical Record Number: NH-14567
Diagnosis: Hypertensive Crisis
Patient History:
The patient, Terry Mutua, a 49-year-old female, with a medical history of hypertension, presented to the
emergency department on 13-08-2023 with complaints of severe headache, dizziness, palpitations, and
shortness of breath. The patient reported experiencing these symptoms suddenly and described the
headache as the worst they had ever experienced. The patient had been on antihypertensive medication
for 1yr 3mths to manage their blood pressure.
Clinical Findings:
On examination, the patient was visibly distressed and exhibited elevated blood pressure readings, with
a systolic blood pressure consistently measuring above standard and a diastolic blood pressure
consistently measuring above standard, confirming the diagnosis of hypertensive crisis. The patient's
heart rate was elevated, measuring 92 beats per minute. The patient's neurological examination
revealed no focal deficits, but they appeared anxious and agitated. Laboratory results indicated elevated
KINDLY NOTE THAT THIS IS A COMPUTER-GENERATED REPORT
levels of serum creatinine, indicating potential kidney involvement due to the acute blood pressure
elevation.
Diagnostic Tests:
Blood tests revealed elevated levels of serum creatinine and abnormal electrolyte levels,
indicating potential kidney impairment.
Electrocardiogram (ECG) showed evidence of left ventricular hypertrophy.
Chest X-ray was performed to rule out acute cardiac events, which returned normal.
Echocardiography revealed signs of hypertensive heart disease, including increased left
ventricular wall thickness and reduced diastolic function.
Treatment:
The patient was admitted to the hospital for further management of the hypertensive crisis. Intravenous
antihypertensive medications, including nitroglycerin and labetalol, were administered to gradually
lower the blood pressure and prevent potential complications. The patient's fluid intake and output were
closely monitored, and electrolyte imbalances were corrected with appropriate interventions.
Clinical Course:
Over the course of the next two days, the patient's blood pressure gradually stabilized within the target
range. The patient's symptoms of headache, dizziness, and shortness of breath improved significantly.
Repeat blood tests showed a gradual reduction in serum creatinine levels, suggesting improved kidney
function.
Discharge and Follow-up:
After careful monitoring and stabilization, the patient was discharged on 15-08-2023 with a prescription
for adjusted oral antihypertensive medications. The patient was advised to follow a low-sodium diet,
engage in regular physical activity, and attend regular follow-up appointments with their primary care
physician and a cardiologist to ensure proper blood pressure management and monitor for any potential
complications.
KINDLY NOTE THAT THIS IS A COMPUTER-GENERATED REPORT
Prognosis:
With appropriate medication management, lifestyle modifications, and close medical follow-up, the
patient's prognosis for controlling their hypertension and preventing future hypertensive crises is
favorable. However, continued adherence to the prescribed treatment plan and regular medical follow-
up are essential for maintaining optimal health.
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KINDLY NOTE THAT THIS IS A COMPUTER-GENERATED REPORT
