What diagnostics should be requested for a 31-year-old female with Chronic Kidney Disease (CKD) stage III, presenting with severe generalized squeezing headache, non-rotatory dizziness, multiple vomiting, and severe hypertension?

Diagnostic Workup for Hypertensive Emergency with CKD Stage III

This patient requires immediate evaluation for hypertensive encephalopathy with brain imaging (CT or MRI), comprehensive laboratory assessment including complete blood count, metabolic panel with creatinine and electrolytes, urinalysis, and ECG, as she presents with severe hypertension (160/120 mmHg) and neurological symptoms (severe headache, dizziness, vomiting) that constitute a hypertensive emergency. 1

Immediate Critical Diagnostics

Neurological Assessment

• Brain CT scan (or MRI with FLAIR imaging) is essential to exclude intracranial hemorrhage and confirm hypertensive encephalopathy/posterior reversible encephalopathy syndrome (PRES), which presents with the exact symptom constellation this patient exhibits 1
• MRI with FLAIR imaging demonstrates increased signal intensity in posterior brain regions characteristic of hypertensive encephalopathy, though CT is adequate for excluding hemorrhage 1
• The combination of severe generalized squeezing headache, non-rotatory dizziness, and multiple vomiting episodes with markedly elevated BP strongly suggests cerebral edema from failed autoregulation 1

Laboratory Analysis (Mandatory)

• Complete blood count including hemoglobin and platelet count to assess for thrombotic microangiopathy (TMA), which can complicate malignant hypertension 1
• Serum creatinine and electrolytes (sodium, potassium) are critical given her baseline CKD stage III—acute kidney injury superimposed on CKD dramatically worsens prognosis 1, 2
• Lactic dehydrogenase (LDH) and haptoglobin to evaluate for TMA associated with malignant hypertension 1
• Quantitative urinalysis for protein and urine sediment examination for erythrocytes, leukocytes, cylinders, and casts to assess for acute glomerular injury 1

Cardiovascular Evaluation

• 12-lead ECG to detect ischemia, arrhythmias, and left ventricular hypertrophy 1
• Fundoscopy is specifically recommended when BP exceeds 180/110 mmHg to identify hypertensive retinopathy and papilledema indicating malignant hypertension 1

Additional Diagnostics Based on Clinical Context

If Cardiac Symptoms Present

• Troponin-T, CK, CK-MB if any chest pain or dyspnea to exclude acute coronary syndrome 1
• Point-of-care cardiac ultrasound or transthoracic echocardiography to assess cardiac structure, function, and pulmonary edema 1
• Chest X-ray if fluid overload suspected 1

If Microangiopathic Hemolysis Suspected

• Peripheral blood smear for schistocyte assessment if platelet count is low or LDH elevated, to distinguish TTP from hypertension-induced TMA 1
• ADAMTS13 activity levels help discriminate TTP (very low activity) from malignant hypertension (normal or slightly reduced activity) 1

CKD-Specific Monitoring Requirements

Baseline Renal Assessment

• Estimated GFR calculation using race-free CKD-EPI equation from serum creatinine 2, 3
• Urine albumin-to-creatinine ratio provides independent prognostic information beyond creatinine alone 2, 3
• Given CKD stage III (eGFR 30-59 mL/min/1.73 m²), complications including electrolyte abnormalities, metabolic acidosis, and anemia become prevalent and require evaluation 1, 3

Electrolyte Monitoring

• Serum potassium is particularly critical as hyperkalemia risk increases with CKD and many antihypertensive medications (ACE inhibitors, ARBs, diuretics) 1, 2
• Metabolic acidosis assessment through serum electrolytes 1

Critical Pitfalls to Avoid

• Do not delay brain imaging when hypertensive encephalopathy is suspected—focal neurological lesions are rare in hypertensive encephalopathy and should raise suspicion for intracranial hemorrhage requiring immediate identification 1
• Do not assume normal kidney function based on "normal" creatinine alone—calculate eGFR as creatinine may underestimate renal dysfunction, especially in women and those with low muscle mass 2
• Do not overlook TMA evaluation in the setting of malignant hypertension with CKD, as BP-lowering treatment improves hypertension-induced TMA within 24-48 hours, whereas TTP requires different treatment 1
• Measure BP in both arms and lower limb to detect pressure differences from aortic dissection, which requires different management 1

Diagnostic Hierarchy

The rate of BP increase is more important than absolute BP value in hypertensive emergencies—there is no specific BP threshold to define hypertensive emergencies because hypertension-mediated organ damage can be present or absent at the same BP level 1. This patient's presentation with emergency symptoms (severe headache, dizziness, vomiting) mandates immediate comprehensive evaluation regardless of the absolute BP reading 1.