Differential Diagnosis
- Single most likely diagnosis:
- Hypertensive urgency: This is the most likely diagnosis given the patient's severely elevated blood pressure (195/105 mm Hg) without evidence of acute end-organ damage. The patient is asymptomatic, and while there are signs of chronic kidney disease and proteinuria, there's no indication of an acute hypertensive emergency.
- Other Likely diagnoses:
- Stage II hypertension: Although the patient's blood pressure is significantly elevated, suggesting a hypertensive urgency, the chronic nature of his condition and the lack of immediate end-organ damage could also align with stage II hypertension if considering his condition over time rather than the acute presentation.
- Chronic kidney disease exacerbation: Given the increase in serum creatinine from 1.30 mg/dL to 1.90 mg/dL, it's possible that the patient's chronic kidney disease is worsening, which could be related to or exacerbated by his hypertension.
- Do Not Miss (ddxs that may not be likely, but would be deadly if missed):
- Hypertensive emergency: Although the patient is asymptomatic and there's no clear evidence of acute end-organ damage (e.g., no ischemic changes on ECG, normal CT head, and no chest opacities), hypertensive emergency is a condition that must be considered due to its potential for severe morbidity and mortality. Conditions such as aortic dissection, pulmonary edema, or intracranial hemorrhage could present subtly at first.
- Renal artery stenosis: This condition could lead to worsening renal function and refractory hypertension. Given the patient's chronic kidney disease and significant hypertension, it's a diagnosis that should be considered, especially if the patient's condition does not improve with standard management.
- Rare diagnoses:
- Pheochromocytoma: A rare tumor of the adrenal gland that can cause episodic or sustained hypertension. It's less likely but should be considered in cases of resistant or severe hypertension without a clear cause.
- Primary aldosteronism: Another rare cause of secondary hypertension, characterized by excessive production of aldosterone, leading to hypertension and hypokalemia. The patient's presentation does not strongly suggest this, but it remains a consideration in refractory hypertension.