A 47-year-old female presented to the emergency department with chest discomfort, numbness, and tingling due to hypertensive emergency. Her blood pressure was extremely elevated at 269/152. She has a history of non-compliance with anti-hypertensive medications. Initial workup found mildly elevated troponins believed to be due to the hypertensive crisis. She was admitted to the intensive care unit for IV anti-hypertensive medications and further cardiac monitoring and testing.

1. ADMISSION DIAGNOSES:
1. Hypertensive emergency.
2. Chest pain with mild troponin elevation, believed to be secondary to
hypertensive emergency.
3. Anxiety status post Ativan therapy in the Emergency Department.
HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old female with well known
non-compliance to anti-hypertensive medication, who presents to the Emergency
Department by the husband’s ______???(01:01) having onset of chest discomfort,
and numbness and tingling in her arms and hands. Attempts of obtaining the
history from the patient has been unsuccessful. The patient is dozing in and
out. The patient received Ativan in the Emergency Department. Thus, I cannot
obtain a history from her. The husband states that she has been short of breath
with exertion over the past several days. No lower extremity swelling. No prior
history of myocardial infarction, congestive heart failure or end-stage renal
disease. Otherwise, no fever, chills or night sweats. No productive cough. No
abnormal bleeding has been noted.
REVIEW OF SYSTEMS: Ten systems review otherwise is without the knowledge of any
additional acute complaints.
PAST MEDICAL HISTORY: As previously stated.
PAST SURGICAL HISTORY: The spouse states three c-sections.
Primary care provider is believed to be out of town physician.
FAMILY HISTORY: Significant for hypertension, strokes and possible heart
disease.
HOME MEDICATIONS: The spouse brings out a bowl of clonidine that appears to be
0.2 mg, cannot read the schedule for it. He states she has not been taking it.
SOCIAL HISTORY: The patient has three children. She is married. She does not
work outside the home, and she has well known noncompliance with her blood
pressure medication by the spouse’s history.
IMMUNIZATIONS: The patient does not take flu or pneumonia vaccines.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: A well-nourished appearing female, who seems somewhat
erratic and all over the gurney followed the periods of sedation.
VITAL SIGNS: In the Emergency Department revealed blood pressure of 269/152 with
pulse 70, respirations 16, and temperature 35.7 Celsius. O2 saturation is 98%.
HEENT: Reveals no obvious icterus or jaundice. Oropharynx is without erythema or
exudates noted.
NECK: Supple without abnormal JVD. No gross focal thyroid masses noted.
LUNGS: With minimal basilar crackles; otherwise, no focus on consolidation or
effusion noted.
CARDIOVASCULAR: The cardiac examination reveals no S3. No rubs or diastolic
murmurs noted.
ABDOMEN: Positive bowel sounds. No rebound. No guarding is noted.
EXTREMETIES: No pitting edema. No sign of DVT or bleeding hemoptysis at this
time.
NEUROLOGIC OBSERVATION: Grossly non-focal.
PSYCHIATRIC OBSERVATION: The patient is sedated and is acting somewhat
erratically. No obvious hallucinations.
LABORATORY DATA: Labs are significant for CBC with a white count of 13400;
otherwise, within normal limits. BMP is within normal limits. Initial troponin
was stated to be mildly elevated.
A 12-lead EKG reveals sinus rhythm with normal axis, increased voltage criteria,
left atrial abnormality, re-polarization abnormality suggestive of LVH with

2. strain.
PLAN: The patient will be admitted to PCU, and clonidine patch/CTS-2 will be
placed. Also, apresoline IV p.r.n. will be initiated and p.o. Norvasc. The
patient will also have IV Lopressor therapy administered. Serial cardiac enzymes
and echocardiogram will be ordered. The patient’s mild troponin was believed to
be secondary to hypertensive emergency. This will need to be followed clinically
for further determination on necessity of inpatient cardiac workup as per the
patient’s clinical course and the attending hospitalist. Also, a Cardiology
consult.
____________________________
Darryl Best, MD
DID 049460
CC:
49460/6010190 / D: 11/07/2012 06:57:15 DT: 11/07/2012 08:02:12 Job#:
8172091 / Voice ID: 7490038
R: 11/07/2012 08:02:12