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LEARNING OBJECTIVES

After completing this case study, the reader should be able to:

  • Distinguish a hypertensive urgency from a hypertensive emergency.

  • Identify treatment goals for a patient with a hypertensive crisis.

  • Develop an appropriate treatment plan for a patient with a hypertensive crisis.

  • Describe how a pharmacist can help improve antihypertensive medication adherence and the importance of providing this education.

PATIENT PRESENTATION

Chief Complaint

“I’m having trouble breathing, and my chest feels tight.”

HPI

Jacqueline Santos is a 59-year-old Hispanic woman who was admitted to the emergency department with a chief complaint of difficulty breathing and chest tightness. She describes shortness of breath that she thinks started a few weeks ago but wasn’t really that noticeable at first. Over the last few weeks, she has noticed her ability to perform daily activities to be more and more limited due to shortness of breath. She is fine when she isn’t doing much, but simple activities such as walking her dog or going grocery shopping cause her to become short of breath rather quickly. Consequently, she moves around more slowly now when doing routine activities. She initially attributed this to just being “out of shape” but now is more concerned that it may be something else. The chest tightness started yesterday and was initially very mild, occurring when she would walk her dog outside and resolving readily with rest. However, it has since gotten more troublesome and is limiting her daily activities. While the chest discomfort still improves with rest, it no longer completely resolves. She tried to self-medicate by taking two doses (500 mg each) of acetaminophen last night and another dose this morning, but she says that didn’t help. She also states that this discomfort is very different from her gastroesophageal reflux pain. While seated in the emergency department she describes the chest discomfort as a 2 on a scale of 1–10 (highest). She has a past medical history significant for HTN and gastroesophageal reflux. She had been taking lisinopril and hydrochlorothiazide for several years with good blood pressure control, but about 6 months ago she stopped taking both medicines, because she had to make an urgent trip to visit her daughter out of state and ended up staying with her for a couple of months. Since her daughter lives in a rural area with no pharmacy nearby, she never got the medications refilled when she ran out. After several days, Ms Santos noticed that she felt just fine despite not taking the medicines. Consequently, she never resumed them and has not seen her provider since.

PMH

HTN × 9 years

Gastroesophageal reflux × 11 years

FH

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