Case Study-A 61 Year Old Male Patient with Chief Complaints of Headaches and Blurred Vision for 4 days
This is a 61-year-old male patient with chief complaints of headaches and blurred vision for 4 days. One thing that stands out from his vital signs is the elevated blood pressure. The 2017 American College of Cardiology/American Heart Association (ACC/AHA) guidelines classify a systolic blood pressure ≥180 mmHg as a hypertensive crisis (Johnson et al., 2019). In this case, the patient presents with a blood pressure of 190/100, which can be considered a hypertensive crisis. Given that elevated blood pressure is associated with headaches, the patient may have been having headaches due to hypertension. Since the patient has hypertension and presents with blurred vision, there is a possible diagnosis of hypertensive retinopathy. Patients with highly elevated blood pressure are at risk of hypertensive retinopathy. Additionally, the patient presents with total cholesterol of 260 mg/dL, LDL of 190 mg/dL, HDL of 35 mg/dL, and triglycerides of 320 mg/dL. Based on the elevated total cholesterol, LDL, and triglycerides, the patient has hyperlipidemia. It has been shown that patients with hypertension and hyperlipidemia are at risk of cardiovascular complications (Zhang et al., 2019). Therefore, it is necessary to determine the ASCVD risk in such patients. In this patient’s case, the predicted risk of a cardiovascular event over the next ten years is 32.0%.
Regarding the plan of care for the patient, he should be admitted to the intensive care unit as recommended by the 2017 ACC/AHA guideline. This should be followed by administering a drug used in hypertensive crises, such as nitroprusside sodium. Within the first hour, the patient’s systolic blood pressure should be reduced by 25%. However, it has to be gradually reduced until it stabilizes at 160/100 mmHg before being reduced further to the normal range within 24-48 hours. Once the pressure is within the normal range, the doses of hydrochlorothiazide and metoprolol will be checked and increased appropriately if not fully optimized. A calcium channel blocker such as amlodipine should be added to the patient’s current regimen if they are fully optimized. Since the patient’s 10-year ASCVD risk is more than 7.5%, he should be put on a moderate- to high-intensity statin like atorvastatin 20 mg once daily. Moreover, the patient will have to visit an optician for an eye examination. This can help detect whether there is hypertensive retinopathy or not. Even though he is expected to recover from the headache once his blood pressure normalizes, he can be given an analgesic such as ibuprofen to reduce the headache as the blood pressure normalizes.
References
Johnson, M. C., Banaag, A. L., Condie, K. J., Servies, T. E., & Koehlmoos, T. L. P. (2019). New ACC/AHA blood pressure guidelines and the operational readiness of naval aviators and aircrew. Aerospace Medicine and Human Performance, 90(4), 409–414. https://doi.org/10.3357/AMHP.5229.2019
Zhang, Y., Vittinghoff, E., Pletcher, M. J., Allen, N. B., Zeki Al Hazzouri, A., Yaffe, K., Balte, P. P., Alonso, A., Newman, A. B., Ives, D. G., Rana, J. S., Lloyd-Jones, D., Vasan, R. S., Bibbins-Domingo, K., Gooding, H. C., de Ferranti, S. D., Oelsner, E. C., & Moran, A. E. (2019). Associations of Blood Pressure and Cholesterol Levels During Young Adulthood With Later Cardiovascular Events. Journal of the American College of Cardiology, 74(3), 330–341. https://doi.org/10.1016/j.jacc.2019.03.529
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Question 
A 61-year-old Black male with a history of hypertension presents to your clinic for complaints of headaches and blurred vision x 4 days. He denies any weakness, numbness, chest pain, shortness of breath, palpitations, or recent, illicit drug use. He states he has been compliant with his medications (hydrochlorothiazide and metoprolol), and he took his meds this morning.
Case Study-A 61 Year Old Male Patient with Chief Complaints of Headaches and Blurred Vision for 4 days
His V/S includes B/P 190/100, P- 90, T- 98.9, and R- 22. Recent labs show that TC- 260, LDL-190, HDL- 35, and Trig- 320. He did not return for these results and did not start any new meds.
What are your diagnoses and plan of care for this patient? Remember to include your rationales.
Length: A minimum of 250 words, not including references
Citations: At least one high-level scholarly reference in APA from within the last 5 years
Example:
This patient presents with 2 main chief complaints, headaches, and blurred vision x 4 days. He has a history of hypertension. His B/P result is elevated at 190/100. As per the Joint National Committee on Hypertension guidelines, the patient is considered in the stage 2 hypertensive category. The patient is exhibiting hypertensive urgency. “In Hypertensive urgencies, there is severe hypertension but the patient or otherwise stable with no evidence of acute or impending change in end-organ damage or dysfunction” (My differential diagnosis would include Asymptomatic high blood pressure, malignant hypertension, or migraines. Asymptomatic high blood pressure: The patient complained of headaches, and blurred vision for 4 days, already taking antihypertensive medication and he follows his medication regularly as prescribed. Renal function should be evaluated. His medication dosage needs to be titrated up as the current dosage may not be sufficient (Whelton et al., 2018). Malignant hypertension: The patient is asymptomatic and found to have a high B/Preading190/100 signs of retinal involvement and complaints of blurry vision. Any signs of hypertension-mediated organ involvement needed to be monitored and managed by the providers (National Guideline Centre (UK), 2019). Migraines: The patient complained of headaches x 4 days (Migraine, 2019). However, more information would be needed. The patient needs to be sent to the emergency room immediately and treatment should be initiated to decrease high blood pressure. The initial goal of the therapy is to reduce mean arterial BP by no more than 25% (within minutes to 1 hour). If the patient remains stable, future reduce the BP to 160 mmHg systolic and 100-110 mmHg diastolic within the next 2 to 6 hours. Normal BP may be targeted over the next 24 to 48 hours (National Guideline Centre (UK), 2019). Providers need to be sensible and cognizant about not reducing BP too fast which could precipitate renal, coronary ischemia, or cerebral vascular accident due to the patient’s previous lab result of high cholesterol levels and it should be avoided (National Guideline Centre (UK), 2019). Diagnostic tests such as chest x-ray and EKGs would be ordered in the ER to rule out cardiac ischemia or cardiomegaly. Lab tests such as CBC and UA would be ordered to evaluate kidney function (National Guideline Centre (UK), 2019). Patients need to be educated on lifestyle modifications such as excessive dietary salt intake, obesity, or alcohol consumption. More information would be needed to evaluate if a patient is taking over-the-counter medication or any herbal supplement (Suneja & Sanders, 2017). Third BP medication such as a calcium channel blocker would be prescribed to manage high BP, Statin would also be prescribed based on the high TC, LDL, and Triglyceride level lab result, and aspirin 81mg would also be prescribed to prevent future atherosclerotic CVA. The patient will need to follow up with the cardiologist based on the recommendation provided in the hospital(National Guideline Centre (UK), 2019