Mrs. Poni, 37 y.o, was referred to ER for recent diagnosis of severe hypertension. Its onset was unknown. She complained of fatigue, headache, and blurred vision.

Her BP was 240/140 mmHg, other vital signs were normal, and physical examination was unremarkable.

Initial laboratory studies: creatinine 2.11, hypokalemia, anemia with thrombocytopenia, and proteinuria of 1.9 g over 24 h. Ultrasound revealed 2 normal-sized kidneys with echogenic parenchyma. ECG: left ventricular hypertrophy, which was confirmed by echocardiography. The LVEF was 58%, and there was no aortic coarctation.

What is the most appropriate investigation should be performed?

1. LDH

2. Fundoscopy

3. Peripheral smear

4. Haptoglobin

Mrs. Cemong, 37 y.o, was referred to ER for recent diagnosis of severe hypertension. Its onset was unknown. She complained of fatigue, headache, and blurred vision.

Her BP was 240/140 mmHg, other vital signs were normal and physical examination was unremarkable.

Initial laboratory studies: creatinine 2.11, hypokalemia, anemia with thrombocytopenia, low haptoglobin, elevated LDH, and proteinuria of 1.9 g over 24 h. Ultrasound revealed 2 normal-sized kidneys with echogenic parenchyma. Retinal examination revealed grade IV hypertensive retinopathy. Peripheral blood smear showed schistocytes.

Most appropriate diagnosis?

Mrs. Clara, 37 y.o, was referred to ER for recent diagnosis of severe hypertension. She complained of fatigue, headache, nausea, and vomiting the night before.

Her BP was 240/140 mmHg, moderately dehydrated, HR 100 bpm, but her other vital signs were normal and physical examination was unremarkable.

Initial laboratory studies: creatinine 2.11, hypokalemia, anemia with thrombocytopenia, low haptoglobin, elevated LDH, and proteinuria of 1.9 g over 24 h, while ultrasound revealed 2 normal-sized kidneys with echogenic parenchyma. ECG: left ventricular hypertrophy, which was confirmed by echocardiography. The LVEF was 58%. Retinal examination revealed grade IV hypertensive retinopathy and schistocytes on peripheral smear. Her head CT was normal.

What would the appropriate treatment?

Mr. Ello, 45 y.o with a 5-hours history of progressive headache presented to the ED with nausea, visual disturbance, and weakness of the right side since 1 hour ago. He had significant medical history of hypertension.

His BP was 195/123 mmHg and HR 122 bpm. On examination, he had a global aphasia, right facial droop, dysarthria, and right hemiplegia. Head CT showed hypodensity in the left middle cerebral artery territory.

If he will be planned for Alteplase intravenous tPA, How would you manage this case?

Mr. Dudung, 58 y.o presented to the ED with nausea, visual disturbance, and weakness of the right side since 2 days ago. He had significant medical history of hypertension.

His BP was 200/115 mmHg and HR 122 bpm. On neurologic examination, he had a global aphasia, right facial droop, dysarthria, and right hemiplegia. General physical examination is unremarkable with no evidences of comorbid conditions. Head CT showed hypodensity in the left middle cerebral artery territory (acute ischemic stroke).

If he was not given Alteplase intravenous tPA, How would you manage this case?

Mr. Beki, 52 y.o with history of hypertension presents to the ED with sudden decreased of consciousness since 5 hours ago. His family states that it started with severe headache and vomiting.

His blood pressure was 225/122 mmHg, GCS 113, HR 100 bpm, and RR 20. A head CT revealed acute ICH in midbrain with no mass effect or edema.

What would the appropriate treatment?

Mrs. Kity Pirry, 35 y.o, with history of migraines and recent diagnosis of hypertension presented with sudden onset of terrible pain located in the occiput and radiating to the forehead, associated with photophobia, nausea, and vomiting. The headache was unlike any she had ever experienced.

Physical examination revealed BP of 190/120 mmHg, HR 118 bpm, RR 18, and GCS 223. CT scan of the head showed a subarachnoid hemorrhage and cerebral angiography revealed multiple aneurysms.

What would the appropriate treatment?

Mrs. Bling, 67 y.o, with history of diabetes mellitus and hypertension, presents with inferior and RV STEMI. She described an abrupt onset of precordial chest pressure, 8/10, that radiated to the jaw and left arm, started 5 h ago with nausea.

On physical examination, BP 180/110 mmHg, HR 92 bpm, regular; RR 20, SaO2 98% on room air, JVP and heart sounds were normal, the lungs were clear, and the extremities were warm. She was in euvolemic state.

What would the appropriate treatment for the high BP?

Mr. Ijong, 74 y.o, with smoking and history of diabetes mellitus and hypertension, presents with anterior STEMI. He became suddenly short of breath, rapidly evolving into pulmonary edema needing endotracheal intubation.

On examination, his HR was 130 bpm, BP 210/120 mmHg, RR 35, bilateral rales, and high JVPs. Cardiac sounds were soft, and there were no murmurs.

What would the appropriate treatment?