Case #2 Answers:

Answer 1
What are her other vitals? Does she have chest pain, neurological signs, or respiratory distress? Has she been having good urine output? Is she in pain anywhere? Ultimately, you are again trying to distinguish hypertensive emergency from urgency in the initial 5 minutes. If she doesn’t have signs of end-organ damage, you have time for more detailed investigation?

Answer 2
Initially, you want to identify any acute events in the hospital that may have precipitated this event. Additionally, you are identifying if this is an isolated event or whether she has had multiple high readings while here. Further investigation should be aimed at noting whether new medicines have been added in the hospital or prior to hospitalization (prednisone, etc.) or medicines that were deleted/forgotten (anti-hypertensives, benzodiazepines, etc.) that could be contributing to her current condition. Recognize that pain, alcohol withdrawal, medication interaction, and drug intoxication are often responsible.

Answer 3

The reason is likely multifactorial. Like most patients with hypertensive urgency, she has a history of elevated blood pressure. She is not currently on an antihypertensive. Additionally, she is likely receiving less morphine than the previous day. Morphine will lower the blood pressure, and less of the does means a greater likelihood of elevated BP. If her sleeping pill was a benzodiazepine, she could certainly have elevation of her BP from this withdrawal of the medicine (even in small doses) as well. Pain is an important consideration, but she currently denies any.

Answer4

Utilizing a medicine that is short acting (6-8hours) may be a reasonable choice until you can speak with the primary care provider in the morning. Oral clonidine has better results than nifedipine in gradual reduction. Recognize that lowering the BP too much may have as much harm as not treating the elevated BP. Falls in hospitalized patients can be precipitated by changes in BP medicines and an inability to maintain cerebral perfusion.