A 39-year-old man is brought to the emergency room by ambulance after he was found
wandering in the street in a disoriented state. He is confused and agitated, and further history is
obtained from his wife. She reports that for the last several months he has been complaining of
intermittent headaches and palpitations, and he had experienced feelings of lightheadedness and
flushed skin when playing basketball. Three weeks ago, he was diagnosed with hypertension and
was started on clonidine twice per day. He took the clonidine for 2 weeks, but because the drug
made him feel sedated, he was instructed by his physician 5 days ago to stop the clonidine and
to begin metoprolol twice daily. On examination, he is afebrile, with heart rate 110 bpm,
respiratory rale 26 breaths per minute, oxygen saturation 98%, and blood pressure 215/132
mmHg, equal in both arms. He is agitated and diaphoretic, and he is looking around the room
but does not appear to recognize his wife. His pupils are dilated but reactive, and he
has papilledema and scattered retinal hemorrhages. He has no thyromegaly. Heart, lung, and
abdominal examinations are normal. His pulses are bounding and equal in his arms and legs. He
moves all of his extremities well, his reflexes are brisk and symmetric, and he is slightly
tremulous. A noncontrast CTof the head is read as negative for hemorrhage. Laboratory studies
include a normal leukocyte count and a hemoglobin level of 16.5 g/dL. Serum sodium level is
139 mEq/L, potassium 4.7 mEq/L. chloride 105 mEq/L, HCO, 29 mEq/L, blood urea nitrogen
(BUN) 32 mg/dL, and creatinine 1.3 mg/dL. Urinalysis is normal, and a urine drug screen is
negative. Lumbar puncture is performed, and the cerebrospinal fluid (CSF) has no cells and
normal protein and glucose.
Summary: A 39-year-old man recently diagnosed with hypertension is now in the emergency
room in an acute confusional state and with critically elevated blood pressures. He has been
having episodes of palpitations, headaches, and lightheadedness. His medication was recently
changed from clonidine to metoprolol. His examination is significant for dilated pupils,
papilledema, and bounding peripheral pulses. The urine drug screen is negative. CT scan of the
head is normal, and CSF studies show no evidence of hemorrhage or infection.
^ Next step: Admit to the intensive care unit, immediate lower blood pressurewith a parenteral
agent, and closely monitor arterial pressure.
Analysis
Objectives
2. Understand the relationship between systemic blood pressure and cerebral blood flow.
Considerations
This is a relatively young man with severely elevated blood pressures who presents with altered
mental status. Use of illicit drugs, such as cocaine and amphetamines, must be considered, but
this patient's drug screen was negative. Hypertensive encephalopathy, a symptom complex of
severely elevated blood pressures, confusion, increased intracranial pressure, and/or seizures, is
a diagnosis of exclusion, meaning other causes for the patient's acute mental decline, such as
stroke, subarachnoid hemorrhage, meningitis, or mass lesions, must be ruled out. Know the
specific etiology of the patient's hypertension is not necessary to treat his encephalopathy;
urgent blood pressure lowering is indicated. However, it is not necessary, and may be harmful,
to normalize the blood pressure too quickly, because it may cause cerebral hypoperfusion.
Parenteral medications should be used to lower the diastolic blood pressure to 100-110 mmHg.
The patient has tachycardia, hypertension, diaphoresis, dilated pupils, and a slight tremor, all
signs of a hyperadrenergic state. Pheochromocytoma must be considered as a possible
underlying etiology of his hypertension. His antihypertensive medication changes may also be
contributoryperhaps clonidine rebound
Caso
Anlisis
Objetivos
Consideraciones
Este es un hombre relativamente joven con presiones sanguneas severamente elevadas que se
presenta con un estado mental alterado. El uso de drogas ilcitas, como la cocana y las
anfetaminas, debe ser considerado, pero la pantalla de drogas de este paciente fue negativa. La
encefalopata hipertensiva, un complejo de sntomas de presiones sanguneas severamente
elevadas, confusin, aumento de la presin intracraneal y / o convulsiones, es un diagnstico de
exclusin, es decir, otras causas del deterioro mental agudo del paciente, como el accidente
cerebrovascular, hemorragia subaracnoidea, meningitis o masa Lesiones, deben ser descartadas.
Conocer la etiologa especfica de la hipertensin del paciente no es necesaria para tratar su
encefalopata; Se indica la reduccin urgente de la presin arterial. Sin embargo, no es necesario, y
puede ser perjudicial, normalizar la presin arterial demasiado rpido, ya que puede causar
hipoperfusin cerebral. Los medicamentos parenterales se deben usar para bajar la presin
arterial diastlica a 100-110 mmHg. El paciente tiene taquicardia, hipertensin, diaforesis, pupilas
dilatadas y un leve temblor, todos los signos de un estado hiperadrenrgico. El feocromocitoma
debe considerarse como una posible etiologa subyacente de su hipertensin. Sus cambios en la
medicacin antihipertensiva tambin pueden ser contributivos, tal vez el rebote de la clonidina