The document details a case presentation of a 35-year-old male with a hypertensive urgency, exhibiting symptoms like headache, dizziness, and vomiting. Initial treatments included antihypertensives and antiemetics, and the provisional diagnosis was supported by investigations such as ECG and renal function tests. Hypertension is classified into urgency and emergencies, with specific management protocols outlined for each category.

1. Emergency Case Presentation
Mr. Kamal raj oli
Health Assistant
Emergency Department
26th Dec. 2019

2. Case Scenario
• A 35 Yrs/male
-presented to ER with C/o
1) Headache for 2 days
2) Dizziness for 2 days
3) Vomiting of 2 episodes for a day
Vitals
BP: 180/120 and 170/120 in right and left arm respectively
Pulse rate: 104
RR: 21, Spo2: 91%in RA
T: 98’F
• what do you do next?
• Differential diagnosis?

3. What do you do next?
• Analgesics e.g.. T. PCM 1gm stat
• Antihypertensive e.g. T. Nifedipine 20mg stat
• Antiemetic e.g. T. ondansetron 4mg stat
• Positioning

4. Differential Diagnosis
• Hypertensive emergency/urgency
• Migraine
• Myocardial infarction

5. History
• Progressive moderate Headache for 2 days at both sides of the head, sometimes
excess in back side , Exceed at the time of exertion, and associated with
sweating, difficulty in looking towards light, there is no H/o chestpain difficulty in
breathing.
• Sudden mild Dizziness for 2 days associated with nausea and vomiting.
vomit contains food particles, there were No H/o blood In vomit.
- Normal B & B habit
• Past History – H/o HTN under Rx for 6 months (i.e T. Amlod-5mg)
No any past H/o migraine,Asthma,Dm and other CVS diz etc
• Personal History -
• Family history -

6. Examination
• GC – Anxious
• PILCCOD – Nil
• BMI : 29.8 (H:5’2 feet,W:74kg)
• Vitals – Pulse: 104b/m; RR=21C/m; Sp02-90%
S/E
• CVS:
• Chest :
• GI: NAD
• CNS: NAD

7. Provisional Diagnosis
• Hypertensive Urgency

8. Investigations
• ECG
• Urine RME
• Renal Function test (urea,cr)
• Chest X-ray
• Opthalmoscopy

9. Final Diagnosis
• Hypertensive Urgency

10. Patient Reassessment
After;T. nifedipine 20mg po stat
T. ondem 4mg
T. pcm
BP: 140/100 mmHg (rt Arm), 140/90 (lft Arm),P:98 b/m,RR = 20 C/m;
No active Nausea vomiting +nt.
Dispatch:

11. Hypertension
Hypertension is a worldwide epidemic.
- Systolic Blood Pressure: >= 140mmHg
- Diastolic Blood Pressure: >= 90mmHg
- someone requiring antihypertensive medications for
control of sustained elevations of blood pressure
• Hypertension can be classified as either Primary or
Secondary hypertension.

12. INTRODUCTION CONT’D
• Essential/Primary hypertension is idiopathic but believed to be a
multifactorial disease process with both genetic and environmental
factors at play.

13. HYPERTENSIVE CRISIS
Not determined by a specific range of elevation in the blood pressure.
Usually,
-SBP: >= 180mmHg
- DBP: >= 120mmHg
CATEGORIES
1. Hypertensive Urgency: Acute severe hypertension without any signs
of damage to target organs (heart, brain, kidneys).
2. Hypertensive Emergencies: Acute severe hypertension with signs of
progressive damage to target organs.

14. History
 History of hypertension
-Duration and patient baseline
-Controlled or Uncontrolled
- Compliant or Non-compliance
 High BP readings
 Co-morbidities
 Evidence of any target-organ damage
 Details of current antihypertensive therapy
 Recreational drug use

15. Examination FINDINGS
 O2 Saturation
 Cardiovascular system
 Check patient’s blood pressure in both arms
Heart Rate
Elevated JVP
Heart murmurs (ischemic mitral regurgitation)
 Basal lung crepitation
 Central Nervous System
- Altered mental status
-Focal neurological deficits

16. Ex FINDINGS Cont.
• Abdomen
Palpate abdominal masses
Auscultate for renal bruits

17. Investigations
• RFT (Urea and Creatinine)
• Urinalysis
• Electrocardiography (ECG)
• Chest X-rays
• CT Brain

18. Management
 Hypertensive Emergency Vs. Hypertensive Urgency
 IV access
 Continuous BP monitoring
 Supplemental O2
The initial goal of therapy in hypertensive emergencies is to reduce
mean arterial pressure by no more than 25% (within minutes to 1
hour), then, if stable, to 160/100 to 110 mm Hg within the next 2 to 6
hours.

19. Any Questions ??