HYPERTENSION
Abigaille A. Chua, M.D.
Objectives
• To present a case of Hypertensive Urgency
• To review the latest guidelines for the
prevention, detection, evaluation and
management of high blood pressure in adults
General Data
• H.T.
• 71/F
• Widowed
• Filipino
• Catholic
Chief Complaint
• Light-headedness
History of Present Illness
2 weeks PTC (+) light-headedness
(+) blurring of vision
BP of 150/100
No other signs and symptoms
Betahistine 24mg prn
Clonidine 75mcg SL
BP of 130/90
No consult was done
History of Present Illness
1 week PTC (+) light-headedness
(+) blurring of vision
BP of 170/90
No other signs and symptoms
ER consult
3 doses of Clonidine SL, BP of
130/70
MGH
History of Present Illness
OTC (+) light-headedness
(+) blurring of vision
BP of 180/100
No other signs and symptoms
Consult with private AP
1 dose of Clonidine SL
Admission
Past Medical History
(+) HPN for > 30 years: Irbesartan, (-) T2 DM
Clonidine 75mcg SL prn (-) Stroke
HBP 200./110 (-) PTB
UBP 120/80 (-) Malignancy
(+) BPPV: Betahistine 24mg prn
(+) Bronchial asthma: Budesonide/
Formoterol (Symbicort) 1 puff BID.
Last attack (~5 years ago)
S/P Tonsillectomy (1963)
Family History
(+) Bronchial asthma, maternal
(+) PTB, sibling
(-) HPN
(-) DM
Personal & Social History
• Non smoker
• Non alcoholic beverage drinker
• Denies illicit drug use
• Worked as a beautician
OB History
• G4P2 (2022)
• Menopause, 53 years old
Review of Systems
Physical Examination
(+) Cataract, OU
Admitting Impression:
Hypertensive Urgency,
Bronchial asthma, not in
acute exacerbation
Course in the Wards
On the day of admission
S O A P
No subjective BP: 140/70 Hypertension Low salt, low fat
complaints Stage II, diet
uncontrolled
(-) headache CBC, Na, K,
(-) lightheadedness BUN, Crea, ALT,
(-) blurring of vision Lipid profile,
FBS, BUA, CXR-
PA, 12L-ECG,
Urinalysis
HEMATOLOGY (08/08/2018) Red Cell indices
CBC Results Reference values MCV L 75.30 80- 100
Hemoglobin L 10.8 11.0-15.0 MCH L 22.80 27.0-32.0
Hematocrit L 35.7 37.0-47.0 MCHC L 30.30 32 - 36
WBC count 5.68 5.0 – 10.0 RDW H 16.10 11.50-14.00
RBC count 4.74 4.2 – 5.4
Differential count Creatine
Neutrophil 69.00 50-70 Result Reference value
Lymphocyte 21.40 20-40
1.01 0.55-1.02 mg/dl
Eosinophil 3.50 0.0-5.0
Basophils 0.30 0.0-1.0
Monocytes 5.80 0.0-7.0
Test Name Result Ref. Range
Fasting blood sugar 96.00 74-106 mg/dl
Blood urea nitrogen 16.00 7-18 mg/dl
Blood uric acid H 8.00 2.6-6.2 mg/dl
Cholesterol 159.00 50-200 mg/dl
Triglycerides 99.00 15-150 mg/dl
VLDL 19.8 < 40 mg/dl
HDL Cholesterol 47.00 1.22
Test Name Result Ref. Range
Calcium L 8.30 8.50-10.10 mg/dl
Magnesium L 1.50 1.8-2.4 mg/dl
Albumin L 3.30 3.40
Urinalysis Urinalysis
Color Light yellow Pus cell 1-2/HPF
Reaction 6.0 RBC 0-2/HPF
Transparency Clear Epithelial cells Rare
Specific gravity 1.010 Leukocytes Trace
Casts None Nitrite Negative
Crystals Few Urobilinogen Normal
Amorphous PO4/Urates
Sugar Negative
Albumin Negative
Ketones Negative
Bilirubin Negative
Blood Trace
Course in the Wards
Hospital day 1
S O A P
No subjective BP: 130/80 Hypertension Shift Amlodipine
complaints Stage II, to Irbesartan
Input: 1420 uncontrolled 150mg/tab OD
(-) headache Output: 1080
(-) lightheadedness Atorvastatin
(-) blurring of 20mg/tab ODHS
vision
For Ca, Alb, Mg
Ca 8.30 Magnesium
Mg 1.50 oxide 1 tablet
Alb 3.30 OD
Course in the Wards
Hospital day 2
S O A P
No subjective BP: 120/80 Hypertension MGH
complaints Stage II,
uncontrolled Home meds:
(-) headache 1.) Irbersartan
(-) lightheadedness 150mg/tab, 4 tabs OD
(-) blurring of vision 2.) Metoprolol
50mg/tab, 1 tab BID
3.) Atorvastatin
20mg/tab, 1 tab ODHS
4.) Magnesium oxide, 1
tablet OD
BP monitoring BID
(AM & PM) & record
Increased uric acid Hypertension
Group 1 Group 2
15 teens with HPN and blood 15 teens with HPN and blood uric
uric acid acid
Allopurinol BID x 4 weeks Placebo
Blood uric acid Only 1 out of 30 had normal BP
Blood pressure (in 20 out of 30)
Reference: Baylor College of Medicine. (2008, August 27). High Levels
Of Uric Acid May Be Associated With High Blood Pressure. ScienceDaily.
Retrieved August 20, 2018 from
www.sciencedaily.com/releases/2008/08/080826190906.htm
Discussion
• Hypertensive emergencies can first be manifested in the
eyes.
Reference: Stacey AW, Sozener CB, Besirli CG. Hypertensive emergency presenting as blurry vision in a
patient with hypertensive chorioretinopathy. International Journal of Emergency Medicine. 2015;8:13.
doi:10.1186/s12245-015-0063-6.
Therapeutic strategies
• Sublingual Nifedipine is contraindicated
2017 Guideline for the Prevention, Detection, Evaluation
and Management of High Blood Pressure in Adults
What’s New?
Hypertension
≥ 130/80 mmHg or higher
140/90 mmHg
Elevated BP
Systolic BP of 120-129 mmHg and diastolic BP of less than
80 mmHg
prehypertension
BP Category Systolic BP Diastolic BP
Normal <120 mmHg And <80 mmHg
Elevated 120-129 mmHg And <80 mmHg
Hypertension: 130-139 mmHg Or 80-89 mmHg
Stage 1
Hypertension: ≥140 mmHg Or ≥90 mmHg
Stage 2
Hypertensive Systolic BP Diastolic BP
Crises
Hypertensive >180 mmHg And/or >120 mmHg
urgency
Hypertensive >180 mmHg + And/or >120 mmHg
emergency target organ + target
damage organ
damage
Schmieder RE. End Organ Damage In Hypertension. Deutsches Ärzteblatt International.
2010;107(49):866-873. doi:10.3238/arztebl.2010.0866.
Diagnostic Tests and other Diagnostic Procedures
Basic testing: Optional:
1. CBC 1. Echocardiogram
2. Lipid profile 2. Uric acid
3. Serum sodium 3. Urinary albumin-
4. Potassium creatinine ratio
5. TSH
6. Urinalysis
7. Electrocardiogram
8. fasting blood glucose
9. serum creatinine with
estimated GFR
10. Calcium
Thank you!
