Case

Sat, 23 Jan 2016 | Clinical Pearls

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.

^ What is the most likely diagnosis?

^ What is the underlying etiology?

ANSWERS TO CASE 1: Hypertensive Encephalopathy/ Pheochromocytoma

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.

Most likely diagnosis: Hypertensive encephalopathy.

^ Possible etiology: Pheochromocytoma.

^ Next step: Admit to the intensive care unit, immediate lower blood pressurewith a parenteral
agent, and closely monitor arterial pressure.
Analysis

Objectives

1. Learn the definition and management of hypertensive emergencies and urgencies.

2. Understand the relationship between systemic blood pressure and cerebral blood flow.

3. Know how to diagnose and medically treat a patient with a pheochromocytoma.

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

Sat, 23 Jan 2016 | Perlas Clnicas

Un hombre de 39 aos de edad es llevado a la sala de emergencias en ambulancia despus de que

fue encontrado vagando por la calle en un estado desorientado. Est confundido y agitado, y se
obtiene ms historia de su esposa. Ella informa que durante los ltimos meses se ha quejado de
dolores de cabeza intermitentes y palpitaciones, y haba experimentado sentimientos de mareo y
rubor en la piel al jugar al baloncesto. Hace tres semanas, se le diagnostic hipertensin y se inici
con clonidina dos veces al da. l tom la clonidina durante 2 semanas, pero debido a que la droga
lo hizo sentir sedado, fue instruido por su mdico hace 5 das para detener la clonidina y comenzar
el metoprolol dos veces al da. En el examen, es afebril, con frecuencia cardaca de 110 bpm,
respiracin respiratoria 26 respiraciones por minuto, saturacin de oxgeno 98%, y presin arterial
215/132 mmHg, igual en ambos brazos. l est agitado y diaphoretic, y mira alrededor de la
habitacin pero no parece reconocer a su esposa. Sus pupilas estn dilatadas pero reactivas, y
tiene papiledema y hemorragias retinales dispersas. No tiene thyromegaly. Los exmenes
cardacos, pulmonares y abdominales son normales. Sus pulsos son delgados e iguales en sus
brazos y piernas. Mueve bien todas sus extremidades, sus reflejos son rpidos y simtricos, y est
un poco trmulo. Un CT de la cabeza sin contraste se lee como negativo para la hemorragia. Los
estudios de laboratorio incluyen un recuento leucocitario normal y un nivel de hemoglobina de
16,5 g / dl. El nivel de sodio en suero es 139 mEq / L, potasio 4.7 mEq / L. Cloruro 105 mEq / L,
HCO, 29 mEq / L, nitrgeno ureico en sangre (BUN) 32 mg / dl y creatinina 1,3 mg / dL. El anlisis
de orina es normal, y el anlisis de orina es negativo. La puncin lumbar se realiza, y el lquido
cefalorraqudeo (CSF) no tiene clulas y protenas normales y glucosa.

^ Cul es el diagnstico ms probable?

^ Cul es la etiologa subyacente?

RESPUESTAS AL CASO 1 : Encefalopata hipertensiva / Feocromocitoma

Resumen: Un hombre de 39 aos recientemente diagnosticado con hipertensin se encuentra

ahora en la sala de emergencias en un estado agudo de confusin y con presiones sanguneas
elevadas. Ha estado teniendo episodios de palpitaciones, dolores de cabeza y aturdimiento. Su
medicamento se cambi recientemente de clonidina a metoprolol. Su examen es significativo para
las pupilas dilatadas, el papiledema y los pulsos perifricos delimitadores. El tamiz de la droga de
la orina es negativo. La TC de la cabeza es normal, y los estudios con LCR no muestran evidencia de
hemorragia o infeccin.

Diagnstico ms probable: encefalopata hipertensiva.

Posible etiologa: Feocromocitoma.

^ Siguiente paso: Admitir a la unidad de cuidados intensivos, bajar inmediatamente la presin

arterial con un agente parenteral y vigilar de cerca la presin arterial.

Anlisis

Objetivos

1. Aprender la definicin y manejo de emergencias y urgencias hipertensivas.

2. Comprender la relacin entre la presin arterial sistmica y el flujo sanguneo cerebral.

3. Saber diagnosticar y tratar mdicamente a un paciente con feocromocitoma.

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