Differential Diagnosis of Hypertensive Urgency

When evaluating a patient with hypertensive urgency on the floor, it's crucial to consider a broad range of potential causes to ensure appropriate management and to avoid missing critical diagnoses. The differential diagnosis can be organized into the following categories:

• Single Most Likely Diagnosis

  • Uncontrolled Essential Hypertension: This is often the most common cause of hypertensive urgency. It occurs when a patient's blood pressure is not adequately managed, leading to a sudden increase. Justification: Essential hypertension is prevalent, and poor adherence to medication, lifestyle factors, or progression of the disease can lead to uncontrolled blood pressure.

• Other Likely Diagnoses

  • Pain or Anxiety: Both can cause a significant increase in blood pressure. Justification: Stress and pain are common on the hospital floor and can exacerbate hypertension.
  • Medication Non-adherence or Resistance: Patients may not be taking their prescribed antihypertensive medications as directed, or the medications may not be effective. Justification: Non-adherence is a common issue, and resistance can develop over time.
  • Fluid Overload: Especially in patients with heart failure or those receiving excessive intravenous fluids. Justification: Fluid overload can increase blood pressure due to increased volume.
  • Sleep Apnea: Can lead to resistant hypertension. Justification: Sleep apnea is common and can significantly impact blood pressure control.

• Do Not Miss Diagnoses

  • Pheochromocytoma: A rare tumor of the adrenal gland that can cause episodic hypertension. Justification: Although rare, missing this diagnosis can be fatal due to the potential for severe, uncontrolled hypertension.
  • Aortic Dissection: A life-threatening condition that requires immediate intervention. Justification: Hypertension is a risk factor for aortic dissection, and missing this diagnosis can be catastrophic.
  • Eclampsia: In pregnant patients, high blood pressure can be a sign of eclampsia, a condition that can lead to seizures and is life-threatening. Justification: Eclampsia is a medical emergency that requires prompt recognition and treatment.
  • Cushing's Syndrome: A hormonal disorder caused by prolonged exposure to high levels of cortisol, which can lead to hypertension. Justification: While rare, Cushing's syndrome can cause resistant hypertension, and its diagnosis is crucial for appropriate management.

• Rare Diagnoses

  • Hyperthyroidism: Can cause increased blood pressure due to increased sympathetic activity. Justification: Although less common, hyperthyroidism can lead to hypertension and should be considered in the differential diagnosis.
  • Hyperparathyroidism: Can lead to hypertension due to increased calcium levels affecting blood vessel function. Justification: This condition is less frequently associated with hypertension but is a consideration in rare or resistant cases.
  • Renal Artery Stenosis: A narrowing of the arteries that carry blood to the kidneys, which can cause hypertension. Justification: This is a less common cause of hypertension but is important to diagnose due to its specific treatment options.
  • Coarctation of the Aorta: A congenital condition characterized by the narrowing of the aorta, which can lead to high blood pressure. Justification: While typically diagnosed in younger patients, it's a rare cause of hypertension that should not be overlooked.