Hypertensive encephalopathy. Patients with hypertensive encephalopathy present with neurologic complaints

including altered mental status, severe headache, seizures,

vomiting, and visual disturbances. The mental status

changes range from drowsiness to confusion to outright

coma.

Intracranial hemorrhage. Patients with intracranial

hemorrhage present with severe headache (often sudden

onset), focal neurologic deficits, and/or altered mental

status.

Acute pulmonary edema. Patients with flash pulmonary edema present with acute shortness of breath. Variable

associated symptoms include orthopnea, hemoptysis, and

chest pain or pressure.

Acute coronary syndrome. Patients with acute coronary syndrome usually present with chest pain, although

subtle signs of congestive heart failure may be the only

presenting complaint.

Aortic dissection. Patients with aortic dissection present with severe chest and/or back pain, often of a tearing

quality. Associated symptoms include neurologic deficits,

syncope, and abdominal pain, as well as constitutional

symptoms such as nausea, vomiting, or diaphoresis.

Acute renal failure. Patients with acute renal failure

often present with relatively subtle symptoms. A earful

history will often elicit hematuria, oliguria, or anuria.

Patients may also present with swelling of the lower

extremities or shortness of breath due to significant fluid

retention.

� Physical Examination

Begin by verifying that the elevated BP reading was

obtained with a cuff appropriately sized for the patient.

Cuffs that are too small will lead to spuriously high BP

readings. The width of the cuff bladder (inflatable portion of the cuff) should equal approximately 40% of the

arm circumference. The length of the cuff bladder should

equal -80% of the arm circumference. Perform a detailed

physical exam, focusing on the neurologic, cardiac, pulmonary, and abdominal examinations. A more detailed

description of expected fmdings related to specific diagnoses follows.

Hypertensive encephalopathy. Check for any signs of

altered mental status. Of note, this can present as only a

subtle confusion. Focal neurologic findings may also be

present and do not always follow the normal vascular

distributions associated with stroke syndromes due to the

global breakdown of the entire cerebral autoregulatory

system. Careful funduscopic examination may reveal retinal hemorrhages and papilledema.

Intracranial hemorrhage. Focal neurologic deficits or

coma may be noted. Meningeal irritation ( eg, nuchal rigidity) may be present in a patient with hemorrhage in the

subarachnoid space.

Acute pulmonary edema. Patients are typically in significant distress. Inspiratory crackles will be present. Lower

extremity edema, jugular venous distention, and an accessory gallop (S3 or S4) may be noted.

Acute coronary syndrome. Patients will often be diaphoretic and may have evidence of heart failure on exam.

Aortic dissection. A blood pressure differential of >20

mmHg between arms or a new aortic insufficiency murmur suggests the presence of an aortic dissection.

Acute renal failure. Physical exam may reveal evidence

of fluid overload but is often rather unremarkable.

DIAGNOSTIC STUDIES

� Electrocardiogram

Perform an electrocardiogram with any suspicion for acute

cardiac ischemia.

� Laboratory

Laboratory studies are most useful to identify end-organ

injury. Obtain a urinalysis (specifically looking for hematuria or proteinuria) and serum blood urea nitrogen and

creatinine to evaluate for acute kidney injury. Check a

urine pregnancy test on all females of reproductive age to

rule out evolving eclampsia. Order cardiac enzymes in

patients complaining of chest pain, back pain, or shortness

of breath.