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Clinical Images

A Shocking Case of Hypertension


Josh Harpool, MD, Stephen Stuart, MD

A 54 year old white female with a past medical history of hypertension and migraines presented to our facility with respiratory failure and shock. Two days prior to admission patient developed flu-like symptoms, cough, and congestion and was initiated on oral antibiotics. She subsequently presented to the outside hospital emergency department with complaints of nausea and vomiting and was found to have an NSTEMI. Upon arrival to our hospital, she was in respiratory distress requiring intubation.  Additionally, she was in a supraventricular tachycardia with a rate of 160 beats a minute with associated hypotension. Her initial chest x-ray exhibited bilateral infiltrates concerning for bilateral pulmonary edema. Bedside echocardiogram showed an ejection fraction less than 25 percent. Patient underwent cardioversion for supraventricular tachycardia and was started on broad spectrum antibiotics, vasopressors, and ionotropes due to concerns for septic and/or cardiogenic shock. 

 

    Following 24 hours of vasopressor support, she became severely hypertensive requiring a nitroglycerin drip for pressure control. She was soon extubated and weaned down to nasal cannula. Repeat echocardiogram revealed a normal ejection fraction.  An incidental finding on CT chest led to CT abdomen and pelvis which revealed the image above.

 

 

Multiple Choice Questions:

1.) What is the next appropriate test to order for this patient?

  1. Serum Cortisol Levels
  2. Serum Renin and Aldosterone levels
  3. Urine metanephrines and normetanephrines
  4. Thyroid Studies  

2.) Which anti-hypertensive(s) are most appropriate for this condition?

  1. Alpha blocker
  2. Ace-Inhibitor
  3. Beta-blocker  
  4. Diuretic
  5. Both A&C

Click here for MCQ Answers and Discussion

Biographies

Stephen Stuart: attended University of Alabama School of Medicine for medical school and is now a PGY-2 in Internal Medicine at UAB.

Josh Harpool: attended the University of Arkansas for Medical Sciences for medical school and is now a PGY-2 in internal medicine at UAB