Learning Objectives:

Knowledge - Students should be able to:

Students should be able to:

• Describe presenting signs and symptoms of a hypertensive crisis/emergency.
• Differentiate between hypertensive urgency and hypertensive emergency based on:
     blood pressure measurement
     detection of acute target organ injury
     association of co-morbid conditions
• Describe major causes of morbidity and mortality in a hypertensive emergency.
• Evaluate clinical factors relevant to therapeutic management such as:
     volume dependency of the hypertension
     effects of concurrent antihypertensive treatment
     duration of underlying chronic hypertension
     associated medical conditions
• Describe the goals of treatment of the hypertensive crisis/emergency.
• Cite the indications for the use of each class of antihypertensive agents.
• Describe the management strategies for the hypertensive crisis and hypertensive emergency.
   

Skills -Students should be able to:

History Taking:

• Determine previous history of blood pressure profile.
• Assess for diagnosis of renal disease, cardiovascular or cerebrovascular disorders, collagen vascular disorders, diabetes mellitus or other endocrine abnormalities.
• Obtain information about symptoms associated with elevated pressures.
• Assess for drug usage that may contribute to elevated blood pressure (birth control pills, nonsteroidal anti-inflammatory agents, appetite suppressants, antihistamines, cocaine).
• Assess for the current usage of antihypertensive medications.

Physical Exam:

• Accurate measurement of blood pressure using the appropriate sized cuff.
• Funduscopic exam to assess for evidence of chronic hypertension as well as acute.
• Cardiovascular exam for prominent or displaced PMI, S3, S4.
• Assess for bruits in the carotid, femoral, renal and aortic vessels.
• Pulmonary assessment for edema.
• Abdominal exam for presence of mass (enlarged kidneys).
• Examine lower extremities for decreased pulses and edema.

Differential Diagnosis:

• Differentiate between a hypertensive crisis and hypertensive emergency recognizing specific history and physical exam findings.

Labortory Interpretation:

• Interpret BUN, creatinine, potassium, urinalysis and electrocardiogram.

Communication Skills:

• If the patient is coherent, should be told the diagnosis, treatment plan and prognosis.

Procedures:

• Placement of an arterial line when continuous blood pressure monitoring is required.

Management Skills:

• Decide if the patient should be admitted to the intensive care unit.
• Order the appropriate type of medication for lowering blood pressure.
• Determine when to switch to oral medication if the patient was on intravenous therapy.
• Prescribe an outpatient regimen for discharge.

Attitudes and Professional Behavior -Students should be able to:

• Appreciate the impact a hypertensive emergency has on an individual.
• Be aware of the associated side effects and costs of the medications that may prevent successful long-term compliance with drug therapy for a typically asymptomatic condition.
• Appreciate the difficulty of lifestyle modifications required (weight loss, cessation of smoking, excercise).

References:

Varon, J. et al. “The Diagnosis and Management of Hypertensive Crises.” Chest, 2000; 118:214-227.

The Seventh Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. The JNC7 Report. JAMA 2003;289:2560-2572..