Hypertension Emergency 101

A 40 year old male with new b/l LE edema, hypertensive emergency, and AKI

PMH: 

None. Presented with 4 weeks of progressive b/l LE edema. Admitted to MICU for hypertensive emergency requiring nicardipine drip. Now improved, transferred to floor for ongoing workup of renal disease, pending biopsy.

Active Problems: Elevated creatinine / suspected glomerulonephropathy

• Most likely: membranous GN (pending biopsy)

• Other considerations: CKD from longstanding uncontrolled HTN vs podocytopathy vs secondary causes

• Preliminary workup: ANA positive, ASO/HBV/HCV/HIV negative. PLA2R, MPO/PR3, SFLC/IFE pending.

• Plan:

  • Renal biopsy with IR once BP <160 sustained (hold DVT ppx beforehand).

  • Strict I/O + daily weights.

  • Lasix 80mg IV PRN, target net neg 2–3L/day.

  • Continue amlodipine 10 mg daily + carvedilol 12.5 mg BID.

  • Hydralazine PO PRN if persistent hypertension.

  • Obtain PTH, follow ANA titer.

Hypertensive emergency (improved)

• Likely precipitated by fluid overload and renal disease.

• BP goal: SBP <150 (<160 for biopsy safety).

• Current regimen: amlodipine + carvedilol, titrate with hydralazine as needed.

• Off nicardipine gtt.

• VS q4h.

Pulmonary edema / volume overload

• CTA chest: no PE; showed pulmonary edema, small bilateral pleural effusions, mosaic attenuation, atelectasis.

• TTE: EF preserved (61%), moderate concentric LVH, moderate MR, mild biatrial enlargement, elevated RAP.

• Supports diagnosis of hypertensive heart disease with volume overload.

• Continue diuresis as above.

Left hand edema

• Duplex US: no DVT.

• Superficial thrombophlebitis at IV site.

• Plan: remove IV, warm compresses, monitor for extension.

Thyroid nodule

• 18 mm right lobe nodule seen on CTA.

• Outpatient thyroid US recommended.

Moderate mitral regurgitation (new)

• TTE showed tethered MV with moderate MR, preserved LV function, elevated filling pressures.

• Likely functional in setting of LVH and volume overload.

• Plan: optimize BP and volume status; outpatient cardiology follow-up after renal diagnosis clarified.

Other Considerations

• Diet: Na-restricted.

• Mobility: Ambulate as tolerated; PT/OT involved.

• Access: PIV only.

• Code: Full.

• Communication: Daily updates to wife.

• DVT prophylaxis: SQH (hold pre-biopsy).

• LOS: Day X

 Big Picture:
Previously healthy 40 years old with hypertensive emergency, now found to have renal dysfunction concerning for glomerulonephropathy (biopsy pending), volume overload with pulmonary edema, and new moderate MR. Currently stable on oral antihypertensives and diuresis, transitioning from MICU to floor-level care.