Differential Diagnosis for Hypertensive Emergency
The patient presents with severely elevated blood pressure, visual changes, and intermittent chest pressure, which indicates a hypertensive emergency. The differential diagnosis can be categorized as follows:
Single Most Likely Diagnosis
- Hypertensive Emergency with End-Organ Damage: This is the most likely diagnosis given the patient's severely elevated blood pressure, visual changes (possibly indicating hypertensive retinopathy or optic neuropathy), and chest pressure (suggestive of cardiac involvement). The presence of end-organ damage (e.g., eyes, heart) classifies this as a hypertensive emergency.
Other Likely Diagnoses
- Chronic Hypertension with Deterioration: Despite being compliant with his medication, the patient's hypertension may have worsened due to various factors such as medication non-resoucher, progression of disease, or secondary causes of hypertension.
- Renal Artery Stenosis: This condition can cause resistant hypertension and could be a contributing factor to the patient's elevated blood pressure readings.
- Pheochromocytoma: Although less common, this condition can cause episodic hypertension and should be considered, especially if other signs such as palpitations, sweating, or headaches are present.
Do Not Miss Diagnoses
- Aortic Dissection: This is a life-threatening condition that can present with severe chest pain and hypertension. It is crucial to rule out aortic dissection in patients with chest pain and hypertension.
- Myocardial Infarction: The patient's intermittent chest pressure could be indicative of myocardial ischemia or infarction, which must be promptly identified and managed.
- Hypertensive Encephalopathy: This condition can present with visual disturbances, headaches, and altered mental status due to severely elevated blood pressure affecting the brain.
Rare Diagnoses
- Cushing's Syndrome: A rare endocrine disorder that can cause hypertension due to excess cortisol production.
- Hyperaldosteronism: A condition characterized by excessive production of aldosterone, leading to hypertension.
- Thyroid Storm: Although rare, thyroid storm can cause significant hypertension among other symptoms, and should be considered in the appropriate context.
Workup and Plan
The workup should include:
- Immediate Blood Pressure Reduction: With intravenous medications to reduce blood pressure gradually.
- Laboratory Tests: Full blood count, electrolytes, renal function tests, liver function tests, and troponin levels to assess for end-organ damage.
- Electrocardiogram (ECG): To evaluate for cardiac involvement.
- Chest X-Ray: To assess for pulmonary edema or cardiomegaly.
- Echocardiogram: To evaluate cardiac function and structure.
- Fundoscopic Examination: To assess for hypertensive retinopathy.
- Further Diagnostic Tests: Based on the initial findings, such as renal ultrasound for renal artery stenosis, or serum and urine tests for pheochromocytoma or other rare causes of hypertension.
The plan involves stabilizing the patient, reducing blood pressure, and managing symptoms while investigating the underlying cause of the hypertensive emergency. Referral to a specialist, such as a cardiologist or nephrologist, may be necessary for further management and to address any underlying conditions contributing to the patient's presentation.