A 55-year-old man is brought to the - a_antibody

[ArchivalUser]

A 55-year-old man is brought to the
emergency department because of
increasing incoherence over the past
24 hours. He has a history of
hypertension and diabetes. He is
disoriented. On physical examination,
he is afebrile. His blood pressure is
230/130 mm Hg, pulse is 120/min, and
respirations are 24/min. He has an S4
on cardiac examination. The patient
is placed on a cardiac monitor, and
IV and intraarterial lines are
placed. A head CT scan shows no mass
or bleed. Which of the following is
the most appropriate next step in
management?


A. Observe in a quiet room

B. Check chemistry for an anion
gap

C. Administer a beta blocker

D. Administer sodium
nitroprusside

E. Perform a lumbar puncture

[ArchivalUser]

go for b????????

[ArchivalUser]

C?

[ArchivalUser]

The correct answer is D. This
patient is having a hypertensive
emergency, given the presence of
end-organ damage in the setting of
hypertension. Hypertensive
encephalopathy counts as an
emergency. Immediate therapy before
the laboratory results are known is
needed. This requires immediate, but
not precipitous, lowering of the
blood pressure over a period of
minutes to hours. Sodium
nitroprusside is used since it
allows titratable blood pressure
reduction.

Observation (choice A) is not
appropriate for this patient, since
he has an emergent medical condition
that needs to be addressed.

Diabetic ketoacidosis or sepsis
(choice B) may present with mental
status changes and an anion gap.
However, the patient most likely has
hypertensive encephalopathy, and
this needs to be addressed first.

A beta blocker (choice C) may reduce
the pulse but will not cause much
vasodilation or arterial dilation,
which is needed to immediately lower
the blood pressure. It may used as
an adjunct therapy. IV labetalol may
prove to be an acceptable
alternative, however.

The patient has mental status
changes, and meningitis is on the
differential. However, management of
the blood pressure should not be
delayed to perform a lumbar puncture
(choice E). Furthermore, he is
afebrile, placing meningitis lower
on the differential

[ArchivalUser]

D. Administer sodium
nitroprusside