On 1 June 2022, a 67-year-old black male farmer who had been experiencing significant chief complaints of shortness of breath for the previous 4 h and an elevated basal blood pressure of 187/102 mm Hg at a nearby clinic for the previous 3 h was admitted to the emergency room. The patient had a 5-year history of hypertension, type 2 diabetes mellitus, Helicobacter pylori-positive peptic ulcer disease, and anemia. The patient had taken medications such as hydrochlorothiazide, metformin, glibenclamide, enalapril, and ferrous sulfate, and triple therapy for peptic ulcer diseases such as omeprazole, amoxicillin, and clarithromycin. The newly hospitalized patient had no prior history of using tobacco, consuming alcohol, or drinking black tea. The patient who was admitted did not know his family's past drug and medical backgrounds. The patient was traveling to the village for a 2-day job but forgot his medication at home, and he lost his consciousness and motor activity at the work site. The patient who was admitted was unconscious and unresponsive for 24 h. A rapid rise in blood pressure brought on by non-compliance with antihypertensive medication is the direct cause of the hypertensive emergency in this patient. The admitted patient presented with symptoms of shortness of breath, disorientation, dizziness, nausea, vomiting, blurred vision, and faintness.
His vital signs upon admission showed a high blood pressure of 194/106 mm Hg, a heart rate of 93 beats per minute, a body temperature of 35.8 C, a respiratory rate of 20 breaths per minute, a weight of 63 kg, a height of 1.76 cm, body mass index of 20 kg/m2, and an oxygen saturation of 91% on room air (Table 1).
Laboratory investigations of the patient revealed: blood urea nitrogen of 29 mg/dL (normal value = 6-20 mg/dL), potassium of 3.7 mmol/L (normal value = 3.6-5.2 mmol/L), sodium of 168 mEq/L (normal value = 135-145 mEq/L), fasting blood glucose of 134 mg/dL (normal value = 100-126 mg/dL), higher density lipoprotein of 56 mg/dL (normal value = 40-60 mg/dL), lower density lipoprotein of 122 mg/dL (normal value = 100-129 mg/dL), triglycerides of 145 mg/dL (normal value = <150 mg/dL), hemoglobin of 13.9 mg/dL (normal value = 13.8-17.2 mg/dL), hematocrit of 47% (normal value = 41%-50%), and serum creatinine of 1.4 mg/dL (normal value = 0.7-1.3 mg/dL), urinalysis revealed urine crystals, white blood cell of 11,340 cells/mm3 (normal value = 4500-11,000 cells/mm3), neutrophils of 67% (normal value = 55%-70%), and lymphocytes of 27% (normal value = 20%-40%). The troponin level in this patient is normal because his hypertensive crises did not lead to a myocardial infarction.
In the course of his physical examination, which included a cardiovascular examination, the heart auscultation of S1 and S2 revealed a heart murmur, an increased jugular venous pressure, crackles, and gallops. An abdominal examination showed abdominal swelling correlated with moderate epigastric tenderness. A head, ear, eye, nose, and throat examination revealed pink conjunctiva. Lung auscultation revealed no pulmonary edema and tiny crackles in the respiratory system. The Glasgow Coma Scale, to determine level of consciousness, gave the right arm a score of 2/5, the right leg a score of 3/5, the left arm a score of 2/5, and the left leg a score of 2/5. All four limbs were feeble. The patient scored a total of 9 on the Glasgow Coma Scale (2 + 2 for the upper extremities and 3 + 2 for the lower extremities). Her lower limbs had no edema and symmetric palpable pulses. No space was found to be occupied by a brain lesion, according to a brain computed tomography scan. The absence of any localizing signs was revealed by magnetic resonance imaging (MRI). An abnormal cardiac region was visible on chest X-rays, and there were no changes to the pulmonary parenchyma or fluid overload. Although there was a rapid heartbeat on the electrocardiogram (ECG), there was no evidence of an arrhythmia or a change in the ventricular repolarization of the anterolateral wall. An echocardiogram revealed healthy cardiac structure and function.
Upon admission, hydralazine (5 mg) intravenously was administered immediately, and he was reassessed after 20 min and kept at the emergency department. After receiving two injections of 5 mg of hydralazine, the patient developed reflex tachycardia. The physician then added 50 mg of atenolol, taken orally once a day, to the treatment plan. On the next day, sustained-release nifedipine (20 mg) was initiated orally twice a day for the patient, and he was transferred to the medical ward. In the medical ward, he was assessed for 4 days, and in those 4 days, he showed marked improvement. The patient received advice as he followed a non-pharmacological approach to managing his hypertension, such as consuming a diet high in whole grains, fruits, and vegetables high in nitrates (leafy vegetables) as part of a dietary strategy to treat his condition. In addition to cutting back on items heavy in sugar, saturated fat, and trans fats, he also avoids adding salt when making food. On 6 June 2022, the physician added nifedipine to his past antihypertensive medication for 1 month and discharged him back to his home. The patient was advised to have a monthly ambulatory care check-up.