Pharmacotherapy Case Study: Hypertensive Crisis by Dr. Nehad Jaser
Pharmacotherapy Case Study: Hypertensive Crisis
Patient Profile: 62-year-old female
Subjective Data
- Chief
Complaint: “My
head is pounding, I can’t breathe well, and I feel confused.”
- History of
Present Illness:
- Sudden-onset
severe headache, blurred vision, and nausea starting 6 hours ago.
- Progressive
shortness of breath and chest tightness.
- Denishes
chest pain radiating to the arm but admits to "pressure" in the
chest.
- No prior
history of similar episodes.
- Medical
History:
- Hypertension
diagnosed 10 years ago; poorly controlled due to inconsistent medication
use.
- Chronic
kidney disease (CKD Stage 3, baseline creatinine 1.8 mg/dL).
- No known
heart failure or diabetes.
- Medications:
- Lisinopril
20 mg daily (last taken 4 days ago due to running out of pills).
- Amlodipine
10 mg daily (non-adherent for 1 week).
- Social
History:
- Smokes 1
pack/day × 40 years.
- No
alcohol or illicit drug use.
- Adherence: “I forget my pills often
and didn’t refill them last month.”
Objective Data
- Vitals:
- BP: 210/130
mmHg (repeated in both arms).
- HR: 110
bpm, RR: 24/min, SpO₂: 92% on room air.
- Temp:
98.6°F, BMI: 28 kg/m².
- Physical
Exam:
- Neurologic: Alert but confused; no
focal deficits.
- Eyes: Papilledema on
fundoscopy, retinal hemorrhages.
- Cardiovascular: Tachycardic, S4 gallop,
no murmurs.
- Lungs: Crackles at bilateral
lung bases.
- Extremities: Mild pitting edema (1+)
in lower legs.
- Labs:
- Creatinine: 3.2
mg/dL (baseline 1.8 mg/dL).
- Troponin:
0.1 ng/mL (mildly elevated).
- BNP: 450
pg/mL (elevated).
- Urinalysis: Protein
2+, RBC 5–10/HPF.
- Imaging:
- Chest
X-ray: Pulmonary
vascular congestion, interstitial edema.
- Head CT: No acute hemorrhage or
infarct.
- ECG: Sinus tachycardia, LVH
with strain pattern.
Assessment
- Primary
Diagnosis:
- Hypertensive
Emergency (BP
≥180/120 mmHg + acute target organ damage).
- Acute
Complications:
- Hypertensive encephalopathy (confusion,
papilledema).
- Acute decompensated heart failure (elevated BNP,
pulmonary edema).
- Acute kidney injury (creatinine rise, proteinuria).
- Contributing
Factors:
- Non-adherence
to antihypertensive therapy.
- CKD,
smoking, and chronic hypertension.
Pharmacotherapy Plan
- Immediate
Management:
- Admit to
ICU for
continuous BP monitoring and organ support.
- IV
Antihypertensive Therapy:
- Nicardipine infusion: Start at 5 mg/hr, titrate to reduce BP
by 20–25% within the first hour (goal: ~160/100 mmHg
within 2–6 hours).
- Transition
to labetalol 20 mg IV bolus if HR remains elevated
(>100 bpm).
- Diuresis
for Pulmonary Edema:
- Furosemide 40 mg IV bolus (repeat as needed).
- Renal
Protection:
- Hold
lisinopril temporarily (risk of AKI progression).
- Long-Term
Control After Stabilization:
- Oral
Antihypertensives (once BP <160/100 mmHg):
- Amlodipine 10 mg daily (restart).
- Carvedilol 12.5 mg BID (to address tachycardia and heart
failure).
- Hydralazine 25 mg TID (if BP remains elevated).
- Avoid
ACEi/ARBs until
renal function stabilizes.
- Non-Pharmacologic
Interventions:
- Sodium-restricted
diet (<2
g/day), fluid restriction (<1.5 L/day).
- Smoking
cessation counseling and referral to a cessation program.
- Monitoring:
- Every
15–30 minutes: BP,
HR, SpO₂, neurologic status.
- Daily
labs: Creatinine,
electrolytes, troponin.
- Follow-up
echocardiogram to
assess LV function.
Patient Education
- Stress lifelong
adherence to medications and consequences of untreated
hypertension.
- Provide
a medication reconciliation sheet and pillbox for
organization.
- Schedule
close follow-up with nephrology and cardiology post-discharge.
Rationale:
- Nicardipine
provides rapid, titratable BP control without compromising cerebral/kidney
perfusion.
- Furosemide
addresses volume overload and pulmonary edema.
- Avoidance
of ACEi prevents worsening AKI in the acute phase.
- Long-term
use of carvedilol and amlodipine improves outcomes in heart failure and
hypertension.
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