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