Clinical Presentation
Signs and Symptoms
Screening for clinical evidence of target organ damage is essential to identify a hypertensive emergency, which requires immediate transfer to a hospital. Hypertensive encephalopathy may present with neurologic symptoms like headache, dizziness, altered level of consciousness, seizures, agitation, and visual disturbances. Focal neurologic findings can occur, although rare, and should raise suspicion of acute ischemic stroke or cerebral hemorrhage. These patients usually have advanced retinopathy with arteriolar changes, hemorrhages, and exudates, along with papilledema.
Patients suspected of aortic dissection may present with severe chest pain, back pain, unequal pulses, and widened mediastinum. Patients suffering from cardiac decompensation may have chest pain or pressure, dyspnea, cough, orthopnea, or pulmonary edema. Renal failure may be suspected if oliguria and/or hematuria are present. Patients may also present with acute myocardial infarction (AMI) or angina. Patients with increased intracranial pressure (ICP) may present with nausea and vomiting. Preeclampsia or eclampsia may develop in pregnant patients with severe hypertension. Patients with acute severe hypertension may present with severe headache, shortness of breath, chest pain, edema, epistaxis, body aches, severe anxiety, or faintness.
A thorough history and physical examination should be quickly performed simultaneously with the initiation of antihypertensive therapy.
History
Hypertensive Crisis_Initial Assesment 1The history should include the duration and severity of hypertension, current prescribed medications and recreational drugs (eg monoamine oxidase inhibitors (MAOI), phenylpropanolamine, cocaine, amphetamines), usual BP control, and comorbid conditions or HMOD (eg potential damage in the cardiovascular, cerebrovascular, or renal system). Previous hypertensive crises and non-compliance to antihypertensive medications should also be asked. Many of the patients with acute severe hypertension are non-compliant with antihypertensives or not adequately treated.
Physical Examination
Hypertensive Crisis_Initial Assesment 2BP measurements in both arms and at least one leg, in supine and standing positions should be done. Use appropriate-sized cuffs and a calibrated BP device.
| RECOMMENDED CUFF SIZES | ||
| Arm Circumference | Description | Cuff Size |
| 22-26 cm | Small adult | 12x22 cm |
| 27-34 cm | Adult | 16x30 cm |
| 35-44 cm | Large adult | 16x36 cm |
| 45-52 cm | Adult thigh | 16x42 cm |
Palpate for pulses; compare in
the upper, femoral, and lower extremities. Careful cardiovascular exams should
include the assessment of jugular venous pressure, checking for the presence of S3 or S4 heart sounds, murmurs,
gallop, or LV heave, and evaluation for lower extremity edema. Auscultate the
carotid and abdominal arteries for bruits. Auscultate lungs for signs of
pulmonary edema (eg rales). A focused neurologic exam and assessment of mental status, and funduscopic exam
to detect papilledema, hemorrhages, or exudates should also be done.