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On to part two of episode 40 of hypertension in the emergency department.

Part one we talked about asymptomatic hypertension and minimally symptomatic hypertension.

And now we're going to go on to talk about the true hypertensive emergencies and some other interesting hypertension-related conundrums.

A 40-year-old man with a past medical history of hypertension and hypothyroidism was brought into

the ED by ambulance with increasing confusion over four hours, according to his wife.

When you go see him, he appeared slightly agitated

with a GCS of 13. His blood pressure was 240 over 140 with a normal heart rate, respiratory rate,

and temp. Glucose was normal. He had no focal neurologic deficits, and his fungi were difficult to

visualize. And ECG showed signs of LVH.

Dr. Atzma, at this point, what would your differential diagnosis be for this patient?

Well, given his blood pressure is 240, I want to recheck that and make sure that really is the case.

And obviously, that's going to move me into hypertensive encephalopathy

on the top of my differential. Other things to consider would be encephalitis in a young patient

who's confused without localizing signs. Epsepsis, if there's an ischemic stroke,

if it's big enough, it's possible, although not very likely. Endocrine causes and, of course,

toxological causes in a young person. There could be sources there and also withdrawal. So those

are things I would consider, although with a blood pressure like that, you know, you're lucky

if you get that right off the start because it can really hone your differential.

Okay. So this patient had a CT that was read as negative. So that rolls out all the

intracranial hemorrhage. Ischemia generally. Yeah. So certainly then you're going to be

going more down that pathway of hypertensive and kephalopathy because that's what you would

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