Hypertensive emergency Polymyalgia rheumatica Hyperlipidemia unspecified Presence of xenogenic heart valve Long term (current) use of systemic steroids Personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits Hypotension due to drugs Do not resuscitate Hypovolemia
 
Name:  ___                    Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 
Allergies: 
amitriptyline / Cholestyramine / Dicloxacillin / diltiazem / 
niacin / amlodipine
 
Attending: ___.
 
Chief Complaint:
Hypertensive emergency
 
Major Surgical or Invasive Procedure:
none

 
History of Present Illness:
___ F with history of severe AS s/p TAVR (___), resistant 
hypertension, PMR on chronic prednisone, and cryptogenic stroke 
(___), presented with dizziness and weakness in the setting 
of BP of 200/110. She was at home on ___ when she felt suddenly 
dizzy.  She called an ambulance and had to lie on her couch. Her 
hands shook. She reports blurry vision, but denies headache. She 
denies fall, head strike, or loss of consciousness. She denies 
heart palpitations or chest pain. She reports no change in 
recent PO's. She additionally denies any dyspnea or headache.  
She does report a history of having "something bad happen" every 
time "a blood
pressure pill gets changed."

Recent hospitalizations that presented with dizziness were 
worked up as per below: 
___: Found to have had a cryptogenic stroke with subacute L 
temporal and R occipital
infarcts
___: Stroke workup negative, presumptive diagnosis was 
L-sided peripheral vestibular disorder

Of note, ___ Cardiology increased her lisinopril dose from 5mg 
to 10mg recently. She reports frequent changes to her 
anti-hypertensives, often with dizziness as the result. 
Medication compliance is unclear as patient lives alone with no 
nursing services. 

In the ED:
- Initial vitals: T 98.6 HR 80 BP 190/110 RR 16 O2 sat 90%
- Administered labetolol 5mg IV, clonidine 0.2mg, lisinopril 
10mg.
- Subsequently however, orthostatics were positive, with SBP in 
the ___, so she received IV NS. 

She was admitted to medicine for BP medication titration.
 
Past Medical History:
Subacute L temporal and R occipital infarcts (cryptogenic stroke 
___
H pylori infection
HTN
Dyslipidemia
Severe aortic stenosis s/p TAVR
PMR
Temporal arteritis
SIADH
Hyponatremia 
Spinal stenosis
Osteopenia
Macular degeneration
Cataracts 
Leukopenia 
Iron def anemia 
Deviated septum
 
Social History:
___
Family History:
Reviewed and found to be not relevant to this illness/reason for 
hospitalization.
 
Physical Exam:
==============
ADMISSION EXAM
==============
Vitals: T 97.8 HR 59 BP 125/74 O2sat 98 Ra
General: alert, no acute distress  
HEENT: MMM, oropharynx clear
Neck: supple, no LAD
Lungs: clear to auscultation bilaterally; no wheezes, rales, or 
rhonchi  
CV: regular rate and rhythm, normal S1 + S2, soft systolic 
murmur
GI: abdomen soft, non-tender, non-distended
Ext: warm, well perfused, 2+ pulses, no edema 

==============
DISCHARGE EXAM
==============
Vitals: 
24 HR Data (last updated ___ @ 733)
    Temp: 98.4 (Tm 98.7), BP: 166/88 (116-224/63-110), HR: 55
(42-64), RR: 16 (___), O2 sat: 98% (94-100), O2 delivery: Ra,
Wt: 104 lb/47.17 kg  
General: No acute distress, sitting up in bed eating breakfast,
nontoxic appearing
HEENT: NC, AT
Lungs: normal WOB on RA, equal chest rise ___
CV: no peripheral edema
Neuro: alert, answers questions appropriately, hard of hearing

 
Pertinent Results:
=============
ADMISSION LABS
=============
___ 09:35PM BLOOD WBC-2.0* RBC-3.90 Hgb-12.4 Hct-35.1 
MCV-90 MCH-31.8 MCHC-35.3 RDW-13.2 RDWSD-43.6 Plt ___
___ 09:35PM BLOOD Neuts-44.9 ___ Monos-18.2* 
Eos-5.1 Baso-0.5 Im ___ AbsNeut-0.89* AbsLymp-0.61* 
AbsMono-0.36 AbsEos-0.10 AbsBaso-0.01
___ 09:35PM BLOOD Glucose-96 UreaN-17 Creat-0.7 Na-135 
K-4.3 Cl-94* HCO3-26 AnGap-15

=============
DISCHARGE LABS
=============
___ 06:10AM BLOOD WBC-1.6* RBC-3.23* Hgb-10.3* Hct-29.9* 
MCV-93 MCH-31.9 MCHC-34.4 RDW-13.3 RDWSD-45.4 Plt ___
___ 06:10AM BLOOD Glucose-92 UreaN-23* Creat-0.7 Na-135 
K-4.4 Cl-97 HCO3-29 AnGap-9*
 
Brief Hospital Course:
___ F with history of severe AS s/p TAVR (___), 
hypertension, and cryptogenic stroke (___), presented with 
dizziness and weakness in the setting of BP of 200/110, admitted 
for labile blood pressures and possible need for med titration.

# Hypertensive emergency with subsequent hypotension
When she arrived to the ED, her anxiety may have caused an acute 
hypertensive emergency. She had recently been uptitated by her 
cardiologist from 5mg to 10mg lisinopril QHS. Med compliance was 
likely contributing in a large part. In the ER, after receiving 
both Lisinopril and Clonidine at the same time, her BP got low 
to SBP 80's. Her lisinopril dose was initially reduced down to 
5mg, but with this her BP rose again. Thus, she was ultimately 
placed back on home Lisinopril 10mg, but told to take in the 
morning rather than at night, to prevent overnight hypotension. 
Continued nightly clonidine 0.2mg QHS.

# Dizziness 
Likely related to BP variations, but some of this is also 
age-related deconditioning. Hypovolemia secondary to poor PO 
intake possible, but this is likely in the setting of periodic 
hypertension.
Recent TTE makes failure of the mechanical AV unlikely. As 
above, Lisinopril continued at 10mg, but timing changed to the 
morning. We gave her instructions on how to stand up safely and 
slowly, and to stay well hydrated.

# Chronic neutropenia - Received heme work-up in past, thought 
to be benign
# Severe AS s/p TAVR - continue ASA and Plavix
# PMR - continue prednisone
# HLD - continue simvastatin

TRANSITIONAL ISSUES
====================
[ ] Lisinopril continued at 10mg daily, but should take it in 
the morning rather than at night. F/u BP further as outpatient.
[ ] Continue to monitor dizziness.
[ ] Continue to monitor blood pressure
 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO QPM 
2. CloNIDine 0.2 mg PO QPM 
3. PredniSONE 1 mg PO BID 
4. Aspirin 81 mg PO DAILY 
5. Simvastatin 20 mg PO QPM 
6. Calcium 500 + D (calcium carbonate-vitamin D3) 500 
mg(1,250mg) -200 unit oral DAILY 
7. Multivitamins W/minerals 1 TAB PO DAILY 
8. Ascorbic Acid ___ mg PO DAILY 
9. Clopidogrel 75 mg PO DAILY 
10. Fish Oil (Omega 3) 1000 mg PO DAILY 

 
Discharge Medications:
1.  Lisinopril 10 mg PO DAILY  
2.  Ascorbic Acid ___ mg PO DAILY  
3.  Aspirin 81 mg PO DAILY  
4.  Calcium 500 + D (calcium carbonate-vitamin D3) 500 
mg(1,250mg) -200 unit oral DAILY  
5.  CloNIDine 0.2 mg PO QPM  
6.  Clopidogrel 75 mg PO DAILY  
7.  Fish Oil (Omega 3) 1000 mg PO DAILY  
8.  Multivitamins W/minerals 1 TAB PO DAILY  
9.  PredniSONE 1 mg PO BID  
10.  Simvastatin 20 mg PO QPM  

 
Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Hypertensive Emergency

 
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - requires assistance or aid (walker 
or cane).
Level of Consciousness: Alert and interactive.

 
Discharge Instructions:
Dear Ms. ___,
  
It was a pleasure caring for you at ___.

WHY WAS I IN THE HOSPITAL?  
- You were feeling dizzy and having trouble with your blood 
pressure.

WHAT HAPPENED TO ME IN THE HOSPITAL?  
- We changed the timing of your lisinopril from night to 
morning.  We kept the dose the same.
- We kept a close eye on your blood pressure.
- You had labwork and an EKG, which looked good.

WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your appointments 
as scheduled.
- Stay well hydrated, drink multiple glasses of water per day
- Take your time when going from a sitting to standing position

We wish you the best!

Sincerely,  
Your ___ Team  

 
Followup Instructions:
___

{'dizziness': ['Hypertensive emergency', 'Hypotension due to drugs'], 'weakness': ['Hypertensive emergency', 'Hypotension due to drugs'], 'blurry vision': ['Hypertensive emergency'], 'shaking of hands': ['Hypertensive emergency'], 'history of severe AS s/p TAVR': ['Presence of xenogenic heart valve'], 'resistant hypertension': ['Hypertensive emergency'], 'PMR on chronic prednisone': ['Polymyalgia rheumatica'], 'cryptogenic stroke': ['Personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits'], 'hypovolemia': ['Hypovolemia']}