Case Presentation
HOPI
The patient is a 48-year-old lady who presents with a 1-day history of giddiness and a 2-day history of blurred vision (BOV), associated with nausea but no vomiting. She also experiences hyperosmolar symptoms.
PMHx
She has a history of hypertension but has defaulted on treatment. Previously, she had no known medical illness (NKMI).
PSHx
Non-smoker, non-alcohol consumer, and single.
Systemic Reviews
- Cardiovascular: Hypertension, cardiomegaly on CXR
- Neurological: Giddiness, BOV, RE INO (right eye internuclear ophthalmoplegia) as per ophthalmology team impression
- Respiratory: No symptoms
- Gastrointestinal: Nausea but no vomiting
Provisional Diagnosis
Given the acute onset of symptoms, particularly the severe hypertension and its effects, a provisional diagnosis of hypertensive emergency is considered.
Differential Diagnosis
- Single Most Likely Diagnosis
- Hypertensive Emergency: Given the severely elevated blood pressure (BP 260/125 and 239/124 on two different readings), symptoms such as giddiness, BOV, and the presence of hyperosmolar symptoms, this diagnosis is highly likely. The patient's history of defaulted hypertension treatment further supports this.
- Other Likely Diagnoses
- Pheochromocytoma: Although less common, this condition can cause episodic or sustained hypertension, along with symptoms like giddiness and visual disturbances due to catecholamine surges.
- Renal Artery Stenosis: This could be a cause of secondary hypertension, leading to the observed severe blood pressure elevations.
- Do Not Miss Diagnoses
- Aortic Dissection: Although the patient does not have typical chest pain, aortic dissection can present atypically, especially in women, and is a life-threatening condition that must not be missed.
- Cerebrovascular Accident (CVA) or Transient Ischemic Attack (TIA): Given the neurological symptoms (giddiness, BOV), it's crucial to rule out a CVA or TIA, especially in the context of severe hypertension.
- Rare Diagnoses
- Cushing's Syndrome: This endocrine disorder can cause hypertension, among other symptoms, due to excess cortisol levels.
- Hyperaldosteronism: A condition characterized by excess aldosterone production, leading to hypertension and potentially hypokalemia, though not directly indicated here.
Each of these diagnoses is considered based on the patient's presentation, history, and the potential consequences of missing a critical diagnosis. The justification for each category is based on the severity of the patient's symptoms, the likelihood of each condition given the clinical context, and the importance of not overlooking potentially life-threatening conditions.