Intern/NF Case 3

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sozme

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Case 3
(Case 1 link - Case 2 link)

Two cases from the ED.

1:
The DNP in the emergency department calls your service saying shes "Got one for ya." 64 y/o African American female suffered sprained ankle chasing her granddaughter around the house. No other complaints, but during triage her BP was found to be 198/127. Her medications include lisinopril and a multivitamin. Her primary care physician is out of town, and she hasn't seen him in 7 months since her lisinopril dose was increased owing to missed follow-up appointment due to work-related emergency.

There are no reported constitutional symptoms, nor is there any chest pain, SOB, headache, nausea/vomiting, visual changes, arm/leg weakness, or recent syncopal episode. Exam reveals pleasant woman in NAD. There is no papilledema, RR with mid systolic ejection murmur, normal S1/S2. Lungs clear. Neuro exam is normal. Her Epic problem list includes "Stage II primary hypertension," "Osteoporosis," and "Tobacco-use disorder." FH is positive for stroke at age 85, and father still alive at 86 in Alzheimer's ward at nearby NH with multiple medical problems. She has private insurance through her job as an administrative assistant at a local university. She lives at home with her husband and is the primary caretaker of two young grand children while her daughter-in-law and son are out of the country for a 2 week archaeology dig in Malaysia.

A variety of tests were ordered in the ED and are as follows: EKG which shows NSR with incomplete RBBB pattern (unchanged from her EKG in the EMR of 3 years ago) and borderline voltage criteria for LVH. CXR is unremarkable. Troponin was 0.01 ng/mL. Serum Mg2+, TSH and free T4 were within normal ranges. Her calcium level is 8.7 mg/dL and Hgb is 11.6 g/dL. BUN/Cr are essentially the same as they were on the CMP done by her primary physician 7 months ago. You recheck BP in both arms and find 195/121 on left, 197/124 on right. Other vitals are normal.

After your exam, patient asks nurse for Advil due to a mild headache which she asserts she recently developed, citing her 8 hour stay in the ER without food and two screaming grand children. The NP wants to give her 20mg IV hydralazine and obtain non-contrast CT head since you are taking an excessive amount of time looking through the EMR and answering other pages.


2:
72-year-old male nonsmoker with a history of diabetes, coronary artery disease, and hypertension who presents with pneumonia and needs to be admitted to the hospital per the ED staff. The patient is febrile and tachypneic, has a blood pressure of 145/65, and has an oxygen saturation of 95% on room air. Physical examination is significant for rhonchi in the right lower lung fields, and a chest x-ray shows a right lower lobe infiltrate. Laboratory studies show a white blood cell count of 14,000 and no evidence of acute renal failure. Blood cultures have been obtained and he is given 500mg IV Zithromax in ED.
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1. Detail your immediate and short-term management (i.e. initial orders, admission orders).

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Ok, ready to make an idiot of myself again.

1:
- There is nothing here to indicate she needs to be admitted. No symptoms to indicate end organ damage, hence no admission needed. The hydralazine thing is probably incredibly dangerous and I would definitely flag down the ED attending before that adventure got started. Im not sure why any of those other tests including a CT were even ordered when she came for an ankle sprain.

Discharge her with Rx for 2.5mg of Norvasc and ask her to see her PC physician at nearest convenience.

Maybe I would be forced to admit her (for political reasons or w/e) in which case I would admit to Obs or something and still just give PO meds. Hopefully attending would come in the next morning and scream at whoever forced us to admit her and she would be out by noon.

2-
Limited info but my understanding is that without some social/compliance reason, this looks like a soft admit as well.



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I'm an intern although my badge doesn't say it and i don't feel like changing it

there's no way either of those patients gets admitted. you don't get admitted for HTN unless its an emergency

the second case is just CAP, give him a shot of ctx and azithro and he's good to go
 
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Two cases from the ED.

HPI
64 y/o African American female sprained ankle chasing someone
triage her BP 198/127.
hasn't seen PCP in 7 months, her lisinopril dose was increased then

While in ED, complains of new onset HA.

ROS
denies consitutional sx, CP, SOB, n/v, vision changes, syncope, limb weakness

ED course:
EKG - NSR with incomplete RBBB pattern (no change from compared with EKG 3 years ago), borderline voltage criteria for LVH.
CXR - unremarkable.
Troponin 0.01 ng/mL.
Serum Mg2+ WNL
TSH and free T4 WNL


PMHx:
Stage II primary HTN
Osteoporosis

Meds:
lisinopril

All:
?

Social Hx:
cigarettes

Social Narrative:
father Alzimer's ward at nearby NH with multiple medical problems. She has private insurance through her job as an administrative assistant at a local university. She lives at home with her husband and is the primary caretaker of two young grand children while her daughter-in-law and son are out of the country for a 2 week archaeology dig in Malaysia.

FamHx:
member had stroke age 85, and father still alive at
Alzheimer's at 86 father

PE

VITALS
WNL except
BP in both arms and find 195/121 on left, 197/124 on right


pleasant woman in NAD.
Eyes: no papilledema
Heart: RR with mid systolic ejection murmur, normal S1/S2.
Lungs: Nl breath sounds bilaterally.
Neuro: exam is normal.

Labs:
normal ranges.
Her calcium level is 8.7 mg/dL
Hgb is 11.6 g/dL.
BUN/Cr same as CMP 7 months ago.

Imaging:
CXR: unremarkable

The NP wants to give her 20mg IV hydralazine and obtain non-contrast CT head since you are busy

Sorry the thing you gave us was a total eyesore.

I agree with head CT because she has HTN and now w/sx. You can't know for sure if HTN vs other cause. But she doesn't have focal neuro signs, so I could be wrong here.
You should add urinalysis to look for casts etc that might be signs of end organ damage. Her Crit/BUN hasn't changed from baseline but I would do it anyway unless I'm wrong here.
Since she doesn't have papilledema or other fundoscopic changes, she has hypertensive urgency, not emergency. Head CT might change that assessment.. She can be watched in obs for now. There's not much evidence for administered hydralazine or other short term agents in a case like this unless CT shows something or she develops more s/sx than HA. She needs an oral regimen to work on getting her pressure down in 1-2 days. If you drop it too fast you risk ischemic stroke. Not sure what you would do to tweak her meds and d/c her. Technically if she can get in with her PCP the next day they could easily adjust it.

2:
72-year-old male nonsmoker with a history of diabetes, coronary artery disease, and hypertension who presents with pneumonia and needs to be admitted to the hospital per the ED staff. The patient is febrile and tachypneic, has a blood pressure of 145/65, and has an oxygen saturation of 95% on room air. Physical examination is significant for rhonchi in the right lower lung fields, and a chest x-ray shows a right lower lobe infiltrate. Laboratory studies show a white blood cell count of 14,000 and no evidence of acute renal failure. Blood cultures have been obtained and he is given 500mg IV Zithromax in ED.
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1. Detail your immediate and short-term management (i.e. initial orders, admission orders)

Full H&P although what we were given was I assume the pertinents

Use PORT score to decide about admission (obviously you might do something not in line with the algorithm depending on clincal picture as a whole)
except I need a CMP for that to calculate
if PORT says low risk, can tx as outpt with azithro 250 mg daily (I don't know how many days TBH)
if high, admit
I need to know just how tachypneic he is to determine via the prompt info
(shoot there's CURB 65 and SMART-COP, not as validated, I use my EMRA white coat Clinical Preditction card and that's what's on there is PORT, Sanford guide to abx has CURB-65})

Admit to Floor
Med Rec
Dx: CAP
Problem List:
DM (1 or 2??)
CAD
HTN
Leukocytosis

Conditon: Stable
Vitals: qshift
Activity: ad lib
Diet: DM, heart healthy
I/Os: ad lib
IVF: none
drains: none
Meds: ct home meds, CTX + Azithro per Sanford guide or else the hospital antibiogram
All: review!
Labs: CMP now, CBC w/diff now and CBC w/o & BMP daily (at some point you could stop doing BMPs and even move to every other day CBC it just really depends), not sure if one dose of azithro makes sputum stain and cx not useful, consider viral panel (not sure here), s pneumo urine Ag, Legionella Ag, some places love to get a procalcitonin
Monitors: continuous pulse ox
Resp care: titrate O2 to keep sat >92, consider HOB >30 degrees if seems higher risk for aspiration
DVT ppx: I prefer the boots to lovenox if I can help it
Notify MD vitals parameters

Shoot I put all this together without Epic holding my hand as it usually does

I used PORT to decide if admit or no
I used Pocket Medicine to help me remember what Ags or other tests to get
I used Maxwell's guide to help me with the admit note (never done it without Epic!)
I used Sanford Guide to Abx to determine inpt vs outpt management of CAP

So this is intern level stuff. I could be off on some of these and an attending can chime in.

Just thought I'd share some thought process, with the one prompt needing overhaul for a real H&P structure
and the other one if more data showed admission was necessary.

EDITED to make clear admission CBC w/ diff, and daily CBC without after
 
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I'm an intern although my badge doesn't say it and i don't feel like changing it

there's no way either of those patients gets admitted. you don't get admitted for HTN unless its an emergency

the second case is just CAP, give him a shot of ctx and azithro and he's good to go

The appropriate thing to do is to change it to say nothing. If you are not a medical student it misrepresents you and is a violation of TOS.
 
daily diffs is a waste; get a CBC with diff on admission and then a daily CBC without diff

I should have made that more clear. Thank you. I edited post to reflect this.

Just a new intern level of thought
 
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The hydralazine line reminded me of these from @name?

Literally the only times I have witnessed acute strokes due to IV BP control was over-anxious medicine residents getting crazy with hydralazine...after a few hemiparetic patients, I decided that drug was off my list.

I feel like hydralazine is a drug that people give when they feel compelled to do something that usually doesn't need to be done--Don't just do something! Stand there

http://forums.studentdoctor.net/threads/asymptomatic-htn.1202033/
 
I agree with head CT because she has HTN and now w/sx. You can't know for sure if HTN vs other cause. But she doesn't have focal neuro signs, so I could be wrong here.
You should add urinalysis to look for casts etc that might be signs of end organ damage. Her Crit/BUN hasn't changed from baseline but I would do it anyway unless I'm wrong here.
Since she doesn't have papilledema or other fundoscopic changes, she has hypertensive urgency, not emergency. Head CT might change that assessment.. She can be watched in obs for now. There's not much evidence for administered hydralazine or other short term agents in a case like this unless CT shows something or she develops more s/sx than HA. She needs an oral regimen to work on getting her pressure down in 1-2 days. If you drop it too fast you risk ischemic stroke. Not sure what you would do to tweak her meds and d/c her. Technically if she can get in with her PCP the next day they could easily adjust it.
What is a CT supposed to show?

I wasn't aware a CT was required for asymptomatic hypertension.

This woman has probably been walking around with a BP that high for months if not years. She is autoregulated in that range. At this point Her cerebral perfusion pressure, coronary PP, RPP etc. all depend on it being that high.

Which is also why "hypertensive urgency" is a pretty dumb term. Sure it might be urgent to the nurses who will doubtless page 4-5x/complain that your doing nothing, but thats actually probably the best thing to do.

I would say that she should be left alone and should be managed strictly outpatient.
The chances of her stroking out simply from high BP are much, much lower than iatrogenic harm 2ndary to someone on the floor going nuts with any combo of hydralazine, clonidine, or even nitrates if they are really stupid.
 
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What is a CT supposed to show?

I wasn't aware a CT was required for asymptomatic hypertension.

This woman has probably been walking around with a BP that high for months if not years. She is autoregulated in that range. At this point Her cerebral perfusion pressure, coronary PP, RPP etc. all depend on it being that high.

Which is also why "hypertensive urgency" is a pretty dumb term. Sure it might be urgent to the nurses who will doubtless page 4-5x/complain that your doing nothing, but thats actually probably the best thing to do.

I would say that she should be left alone and should be managed strictly outpatient.
The chances of her stroking out simply from high BP are much, much lower than iatrogenic harm 2ndary to someone on the floor going nuts with any combo of hydralazine, clonidine, or even nitrates if they are really stupid.

She mentioned new onset HA while in ED. So I can't say she's w/o sx. It could be as she said and just from noise in ED. But it could also herald a burst aneurysm and brain bleed. It's great she doesn't have focal signs. Still, could push her from HTN urgency to HTN emergency. So HTN w/o fundoscopic changes and e/o end organ damage and wi/o sx, can go. But it depends what you make of her new onset HA.

Maybe that doesn't buy you a CT head, I dunno. I recall a similar case and ED got CT. But is that a case of shot gun? I dunno.

Also, I didn't make up the terms or categories for malignant vs urgent vs emergent HTN crises. I just use what I'm given.
 
If the patient with pneumonia met criteria for admission, would you give steroids?

You're killing me here. I wanna say no. They shouldn't have COPD being a non-smoker. I don't see it in the guidelines I have, but I admit I'm usually not up to date.

I should correct my plan, the Sanford guide does list tx duration
 
She mentioned new onset HA while in ED. So I can't say she's w/o sx. It could be as she said and just from noise in ED. But it could also herald a burst aneurysm and brain bleed. It's great she doesn't have focal signs. Still, could push her from HTN urgency to HTN emergency. So HTN w/o fundoscopic changes and e/o end organ damage and wi/o sx, can go. But it depends what you make of her new onset HA.

Maybe that doesn't buy you a CT head, I dunno. I recall a similar case and ED got CT. But is that a case of shot gun? I dunno.

Also, I didn't make up the terms or categories for malignant vs urgent vs emergent HTN crises. I just use what I'm given.
Malignant HTN isn't a term I see in use.

HTN is only an emergency if it's an actual hypertensive emergency (aortic dissection, MI, intracranial hemorrhage, encephalopathy, acute pulmonary edema, eclampsia, etc.).
 
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Malignant HTN isn't a term I see in use.

HTN is only an emergency if it's an actual hypertensive emergency (aortic dissection, MI, intracranial hemorrhage, encephalopathy, acute pulmonary edema, eclampsia, etc.).

So she reports new onset HA. You going to give her tylenol and send her home?
 
Malignant HTN isn't a term I see in use.

HTN is only an emergency if it's an actual hypertensive emergency (aortic dissection, MI, intracranial hemorrhage, encephalopathy, acute pulmonary edema, eclampsia, etc.).

http://emedicine.medscape.com/article/241640-overview

I read that more and more the term being use instead is hypertensive emergency. However I've seen malignant hypertension used plenty. Older docs too.

Are you a med student? Just curious.
 
Ok, ready to make an idiot of myself again.

1:
- There is nothing here to indicate she needs to be admitted. No symptoms to indicate end organ damage, hence no admission needed. The hydralazine thing is probably incredibly dangerous and I would definitely flag down the ED attending before that adventure got started. Im not sure why any of those other tests including a CT were even ordered when she came for an ankle sprain.

Discharge her with Rx for 2.5mg of Norvasc and ask her to see her PC physician at nearest convenience.

Maybe I would be forced to admit her (for political reasons or w/e) in which case I would admit to Obs or something and still just give PO meds. Hopefully attending would come in the next morning and scream at whoever forced us to admit her and she would be out by noon.

2-
Limited info but my understanding is that without some social/compliance reason, this looks like a soft admit as well.



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Nobody's an idiot in these threads. Thank you for stepping up first.

The first one is not an easy discharge. Hypertensive urgency is a dynamic situation that could escalate and needs some kind of follow-up. Happy to send out the door with lisinopril (if not compliant) or add on a thiazide with next day PCP follow-up. Here's the problem: falls risk with nobody at home makes me worried to mess around with antihypertensives, and this patient doesn't seem good with follow-up. The neurologists I've worked with are much more keen to treat (slowly and sanely) hypertensive urgency, especially in the context of CV risk factors, of which this woman has several. But the EM consultants mostly want her out the door with PCP follow-up, but not too sussed about when (ideally next day, but there's next day and there's "next day"). Both seem reasonable to me, and the neurologists don't have great evidence to support their view (certainly no mortality benefit).

Regarding the headache: Who did the neuro exam? I'm personally double-checking before discharge, but in the absence of any acute neurological deficits, I'm happy to send home without CT. Hydralazine is dangerous here. People have adaptations in cerebral perfusion at higher MAP. Slower is generally better, hence I'm keen to get her out the door, preferably restarting lisinopril (if not compliant) or throwing on a thiazide with next day follow-up.

The second one: azithro doesn't seem adequate coverage and lots of communities have a pretty high prevalence of macrolide-resistant strep pneumoniae anyways (check whatever ID puts out monthly). He's also presumed septic with risk factors for progression to septic shock. I'm expanding coverage with ceftriaxone and clinically assessing fluid status. (I don't agree with the SS guidelines in this regard and think the literature argues against getting then too wet.) Happy to let SpO2 to sit where it is but backup is HFNC as per FLORALI if desats < 88. Want a baseline EKG for this guy with CAD.
 
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Which is also why "hypertensive urgency" is a pretty dumb term.

It's tricky. To my knowledge, there's no evidence of mortality benefit. But absence of evidence is not evidence of absence. And I'm more reluctant to let things go with this woman's comorbidities and risk factors for an acute event. Days, not hours, though. I think thiazide (if actually compliant with lisinopril) and out the door with next day outpatient follow up would be ideal.
 
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I mean I get that the HTN one doesn't need admission. But 2.5 mg amlodipine? Come on now. That dose isn't fit for my dog.

And in the real world, some of these hypertensive patients will get admitted. You'll just have to deal with it. They will be easy admissions and dispos for you. But I'll tel you in the community ED's we get plenty of referrals from PMD's to admit their hypertensive "VIP" patients.
Well I thought ccb was better than other options so that her Cr wont be affected by a med when her PCP checks it as outpatient. 2.5 may not help but it wont hurt which is more important. I dont think this is a dynamic situation bc as already mentioned by others, she has had this degree of Htn for a long time.

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Two good cases, I'll add some input.

Case 1: you will see a lot of trauma in your career in most avenues of medicine. For young people it is usually straight forward, very little thinking, and a lot of radiation. For the elderly it becomes more tricky. Did the patient sprain their ankle because they tripped over their dog or did they sprain it secondary to syncope or another medical reason. From the HPI here, it seems more like a mechanical fall, all is good there.

For asymptomatic htn, the American College of Emergency Physicians basically says give them a kiss on the forehead and good follow up. The question here is, is this asymptomatic htn? The answer: we don't know! That's why we order tests and have differentials. Does she have a headache from not eating anything all day or is this headache a bleed related to her trauma? Is her blood pressure truly primary or secondary? If secondary, is it secondary to the ankle pain or something in her head? I think a CT of the head is warranted given her pressure which you have no baseline for, her headache, and the trauma. Admission for this patient would be based upon the results of the scan, response to treatments, patient comfort, etc. I would also refrain from monkeying around with her pressure until the results of the scan come back as you could affect her cerebral perfusion pressure in a negative way with overaggressive reduction in her MAP. Then you would have to deal with a very angry neurosurgeon which is not a pleasant thing.

The worst thing you can ever do though is underestimate trauma in an elderly patient. Don't ignore symptoms. Don't ignore findings just because they don't fit the picture you want to paint. I once had an elderly patient have 3 separate intraparenchymal bleeds at once from rolling out of bed.

Case 2: This is sepsis in an elderly patient with multiple medical comorbidities but probably relatively normal lung function since they are a non-smoker. Screen for HCAP by asking about recent admissions/exposure/risk factors, get a lactate (because you have to now), add antibiotics appropriately and recommend admission. Azithromycin alone is not sufficient. This is an easy sell, would have no problem with admission.
 
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Case 1: The correct answer is home with close PCP follow up. That said, I would absolutely be OK with some Norvasc - usually 5 but that's just what I do, no evidence behind that particular dose. It won't be enough to cause her to stroke out for autoregulation, but enough that we can keep it from getting high enough to cause any damage over the next few weeks. The CT scan question is tricky. I wouldn't fault anyone for doing or not doing it.

Case 2: I can definitely agree with admission, especially if he's tachypneic. With his age and comorbidities, that dude is just begging to get really sick if you send him home. Absolutely not single coverage with zithromax. You can sometimes get away with that in young, healthy patients depending on your local resistance patterns, but given his comobidities either respiratory quinolone, beta-lactam + macrolide, or doxy.
 
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You're killing me here. I wanna say no. They shouldn't have COPD being a non-smoker. I don't see it in the guidelines I have, but I admit I'm usually not up to date.

It's a tricky question. Adjunctive steroids seems to improve outcomes in CAP (has nothing to do with COPD). It's controversial how sick a patient should be for the benefit to outweigh the adverse effects of steroids. Here are some meta-analyses in the last year: http://www.uptodate.com/contents/tr...-who-require-hospitalization/abstract/113-115 Seems like if someone needs ICU care for CAP, then do steroids for sure. Inpatient non-ICU, maybe.
 
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It's a tricky question. Adjunctive steroids seems to improve outcomes in CAP (has nothing to do with COPD). It's controversial how sick a patient should be for the benefit to outweigh the adverse effects of steroids. Here are some meta-analyses in the last year: http://www.uptodate.com/contents/tr...-who-require-hospitalization/abstract/113-115 Seems like if someone needs ICU care for CAP, then do steroids for sure. Inpatient non-ICU, maybe.
Yeah I thought about that study when she posted that and it does look promising - might be worth waiting a year while all the academics try to prove/disprove that study before we all start giving out solu-medrol though
 
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Malignant HTN isn't a term I see in use.

HTN is only an emergency if it's an actual hypertensive emergency (aortic dissection, MI, intracranial hemorrhage, encephalopathy, acute pulmonary edema, eclampsia, etc.).

If you're not a med student but a resident, I suggest changing your status from medical student to either resident or no status at all.
It's a TOS violation to misrepresent this way. You probably didn't do this on purpose, just saying in case you forget to adjust it.

Knowing were people are in training helps readers to know how much weight to give responses.

Myself, I'm at the new intern level as far as anything goes.
 
She mentioned new onset HA while in ED. So I can't say she's w/o sx. It could be as she said and just from noise in ED. But it could also herald a burst aneurysm and brain bleed. It's great she doesn't have focal signs. Still, could push her from HTN urgency to HTN emergency. So HTN w/o fundoscopic changes and e/o end organ damage and wi/o sx, can go. But it depends what you make of her new onset HA.

Maybe that doesn't buy you a CT head, I dunno. I recall a similar case and ED got CT. But is that a case of shot gun? I dunno.

Also, I didn't make up the terms or categories for malignant vs urgent vs emergent HTN crises. I just use what I'm given.

It depends. When you say, "She has a headache," and she's sitting up in bed watching TV? No, it does not herald a brain bleed.

If you say, "She has a headache," and she is in so much pain that she can barely remember her last name? That could be a stroke.

But if it's a mild headache and she's otherwise walking, talking, alert, then it's probably nothing.

Remember - never treat just numbers or catch phrases. Always treat the clinical presentation.
 
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Ok, ready to make an idiot of myself again.

1:
- There is nothing here to indicate she needs to be admitted. No symptoms to indicate end organ damage, hence no admission needed. The hydralazine thing is probably incredibly dangerous and I would definitely flag down the ED attending before that adventure got started. Im not sure why any of those other tests including a CT were even ordered when she came for an ankle sprain.

Discharge her with Rx for 2.5mg of Norvasc and ask her to see her PC physician at nearest convenience.

Justify your choice of Norvasc. (Not saying that I disagree, just wanted to see your reasoning.)
 
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Justify your choice of Norvasc. (Not saying that I disagree, just wanted to see your reasoning.)
Well I figured that using a low dose CCB would be beneficial insofar as it will not affect her GFR, Cr so when her primary physician gets a CMP he/she will not have to wonder if any perturbations are due to a new thiazide or ACEi. @VA Hopeful Dr gave me that idea.

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Well I figured that using a low dose CCB would be beneficial insofar as it will not affect her GFR, Cr so when her primary physician gets a CMP he/she will not have to wonder if any perturbations are due to a new thiazide or ACEi. @vahopefuldr gave me that idea.

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Good answer.

Also, JNC 8 is pretty clear that ACE-inhibitors as monotherapy for BP reduction in African American patients is not a good idea.

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Justify your choice of Norvasc. (Not saying that I disagree, just wanted to see your reasoning.)

JNC-8 guidelines
In the general black population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic or CCB.

For general black population: Moderate Recommendation – Grade B

For black patients with diabetes: Weak Recommendation – Grade C

http://jama.jamanetwork.com/article.aspx?articleid=1791497
 
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If you're not a med student but a resident, I suggest changing your status from medical student to either resident or no status at all.
It's a TOS violation to misrepresent this way. You probably didn't do this on purpose, just saying in case you forget to adjust it.

Knowing were people are in training helps readers to know how much weight to give responses.

Myself, I'm at the new intern level as far as anything goes.
Unless there's a way to do that on the Android app, I'm unlikely to update it. There wasn't a way to do it last time I checked.
 
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Well I figured that using a low dose CCB would be beneficial insofar as it will not affect her GFR, Cr so when her primary physician gets a CMP he/she will not have to wonder if any perturbations are due to a new thiazide or ACEi. @VA Hopeful Dr gave me that idea.

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I like the choice of amlodipine, especially if you feel compelled to start something prior to sending someone home from the emergency department. I would get nervous in that situation if I had ordered something that would merit a follow-up metabolic panel that may or may not get done as I send this stranger off into the great unknown.

That being said, 2.5mg may as well be a gummy bear in terms of what it will do to someone with that blood pressure.
 
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Uh, if I got a head CT every time I had a HA in the hospital I'd be glowing by now

So I looked into this further - and some of your ability to catch early signs of increased intracranial pressure relies on the fundoscopic exam (*cough* *cough*, you totally can rule out the following from your non-dilated fundoscopic exam in the brightly lit ED)

The presence of new retinal hemorrhages, exudates, or papilledema suggests a hypertensive emergency

hypertension-27-638.jpg


http://emedicine.medscape.com/article/1952052-overview
http://emedicine.medscape.com/article/241640-overview

For anyone that thought that malignant HTN and these other terms I just made up. The reason you just hear hypertensive urgency and emergency, and no one mentions malignant, is because it is one type of HTNive emergency - and you only make the diagnosis based on how good your eye exam was in seeing papilledema. I've heard it suggested the term is falling out of favor as physicians spend less time on some parts of the physical exam. So out with the specific term and in with wastebucket HTNive emergency.

You have not performed a complete neuro exam without a good fundoscopic exam. You cannot convince me there is no end organ damage because the neuro exam was non-focal unless you've seen the retina with reasonable detail. No papilledema doesn't cut it either.

So, if you can honestly tell me her fundoscopic exam is clean, then we can declare no end organ damage of the CNS.
(because the only part of the brain you can see without a scan is the optic nerve! and an internist once told me if you master the eye exam you would be able to read their PMHx from their retina. Probably hyperbolic, point is there's data there and it's low cost low harm. [Don't tell me how dilating them just precipitated acute angle closure glaucoma and how dare I! because diagnosing that now could save their vision down the line.] It does require time, patience, skill, and practice.) The prompt gives you no papilledema to take that away as a gimme - this would make this a simple malignant hypertension dx with a protocol. The prompt is wanting you to consider her social factors, etc.

6 most dangerous cause of HA to rule out:
Bleeding
Infxn
Temporal arteritis
Tumor or other causes of acute intracranial pressure, such as hypertensive crisis
Opthalmological
CO Poisoning

I did run across a paper that suggested in the patients with hypertensive urgency, that complain of new onset HA, that it would not be unreasonable to give them something for the HA (APAP? ffs this lady can have some juice!), anxiety, and put them in obs and recheck a BMP in 8 hours, and cross your fingers for placebo or time or whatever. If it all seems unchanged or improved, you're home free. Due diligence, d/c. Now, I'm seeing that the prompt gives you the gimmes of no papilledema and 8 hours in ED already.

If you're really set on wanting more data to base a decision for a CT, some have suggested that you might have to consider empiric lowering of the pressure a touch to see if that helps (it might in some tiny proportion of patients, but of course the fine line of not dicking around and stroking them out, so many reasons that could be a disaster, but I ran across the idea), or none of the above, you're sending her home of the basis of your eye exam and her HA.

So if you're not going to do the CT for new onset HA in hypertensive urgency to r/o emergency, then please do a very good eye exam. Notice that is a cringeworthy one-liner for summarizing what you didn't do in someone that goes home and strokes out in the next 24-48 hrs.

Standard in the ED vs floor affects management.

I basically saw this exact case in the ED, and they imaged her and I'm just basically defending that. That's defensive medicine! Because the overlords said so!

That's all I got. Something I saw, what happened, and some things I remembered from medical school - some of it from overlords that wrote papers I read and some from overlords in person.

I bet my overlord can beat yours.
 
So I looked into this further - and some of your ability to catch early signs of increased intracranial pressure relies on the fundoscopic exam (*cough* *cough*, you totally can rule out the following from your non-dilated fundoscopic exam in the brightly lit ED)

The presence of new retinal hemorrhages, exudates, or papilledema suggests a hypertensive emergency

hypertension-27-638.jpg


http://emedicine.medscape.com/article/1952052-overview
http://emedicine.medscape.com/article/241640-overview

For anyone that thought that malignant HTN and these other terms I just made up. The reason you just hear hypertensive urgency and emergency, and no one mentions malignant, is because it is one type of HTNive emergency - and you only make the diagnosis based on how good your eye exam was in seeing papilledema. I've heard it suggested the term is falling out of favor as physicians spend less time on some parts of the physical exam. So out with the specific term and in with wastebucket HTNive emergency.

You have not performed a complete neuro exam without a good fundoscopic exam. You cannot convince me there is no end organ damage because the neuro exam was non-focal unless you've seen the retina with reasonable detail. No papilledema doesn't cut it either.

So, if you can honestly tell me her fundoscopic exam is clean, then we can declare no end organ damage of the CNS.
(because the only part of the brain you can see without a scan is the optic nerve! and an internist once told me if you master the eye exam you would be able to read their PMHx from their retina. Probably hyperbolic, point is there's data there and it's low cost low harm. [Don't tell me how dilating them just precipitated acute angle closure glaucoma and how dare I! because diagnosing that now could save their vision down the line.] It does require time, patience, skill, and practice.) The prompt gives you no papilledema to take that away as a gimme - this would make this a simple malignant hypertension dx with a protocol. The prompt is wanting you to consider her social factors, etc.

6 most dangerous cause of HA to rule out:
Bleeding
Infxn
Temporal arteritis
Tumor or other causes of acute intracranial pressure, such as hypertensive crisis
Opthalmological
CO Poisoning

I did run across a paper that suggested in the patients with hypertensive urgency, that complain of new onset HA, that it would not be unreasonable to give them something for the HA (APAP? ffs this lady can have some juice!), anxiety, and put them in obs and recheck a BMP in 8 hours, and cross your fingers for placebo or time or whatever. If it all seems unchanged or improved, you're home free. Due diligence, d/c. Now, I'm seeing that the prompt gives you the gimmes of no papilledema and 8 hours in ED already.

If you're really set on wanting more data to base a decision for a CT, some have suggested that you might have to consider empiric lowering of the pressure a touch to see if that helps (it might in some tiny proportion of patients, but of course the fine line of not dicking around and stroking them out, so many reasons that could be a disaster, but I ran across the idea), or none of the above, you're sending her home of the basis of your eye exam and her HA.

So if you're not going to do the CT for new onset HA in hypertensive urgency to r/o emergency, then please do a very good eye exam. Notice that is a cringeworthy one-liner for summarizing what you didn't do in someone that goes home and strokes out in the next 24-48 hrs.

Standard in the ED vs floor affects management.

I basically saw this exact case in the ED, and they imaged her and I'm just basically defending that. That's defensive medicine! Because the overlords said so!

That's all I got. Something I saw, what happened, and some things I remembered from medical school - some of it from overlords that wrote papers I read and some from overlords in person.

I bet my overlord can beat yours.
And this right here is the difference between academic internal medicine and everyone else...
 
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