Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in.
A 56-year-old man with a 10-year history of hypertension presents for a primary care visit, stating he has not taken his high blood pressure medications, which include a calcium channel blocker, an angiotensin-converting enzyme inhibitor, and a thiazide diuretic for the past three months due to “running out of the medication and not getting to the pharmacy.” Today, his blood pressure is 192/120 and he's without complaint, denying shortness of breath, chest pain, or visual changes. He states, “I just came in today for a visit because I ran out of the high blood pressure refills. I need to get back to work in a half hour.” His physical exam is normal, with the exception of which of the following:
An S4 heart sound. Grade 3 hypertensive retinopathy. Neck pain distention. Murmur of aortic regurgitation.
The correct answer is A. An S4 heart sound.
Where do you start? First, determine what kind of question this is. Given that we're being asked for anticipated components of the clinical presentation, this is an assessment question.
Some background information: Keep in mind, this patient has a 10-year history of high blood pressure and admits to nonadherence with a three drug regimen. And when you see that patients need at least three meds to maintain blood pressure control, which is what we have to assume from the data given to us, that tells you they're quite capable of pushing their blood pressures rather high.
I suspect a few of you felt like you had an elevation in your blood pressure when you read what this patient's blood pressure was. But as a result, while off the meds the patient’s BP is really high. At the same time, the patient is without signs and symptoms of problematic markedly elevated blood pressure. What condition do we label this patient as having?
It's called hypertensive urgency. You note the word there: urgency. Defined as a severe blood pressure elevation in a patient who's otherwise stable and without acute or impending changes in hypertensive target organs. The lack of target organ dysfunction or hypertension, often abbreviated TOD. What do you need to do to interpret this? Is keep in mind what the primary target organs of hypertension are. These include the brain, eye, heart and kidney. How can I say with any degree of surety that there is no accelerated hypertensive TOD here? What is he telling us? He has no chest pain, no shortness of breath, no visual changes, and his physical exam is within normal limit parameters. Please note that's in there with the exception of simply a single finding.
Typically, in hypertensive urgency, the history is as we've seen here. Patient has a history of a significant number of years of high blood pressure and has discontinued or not adherent to the previously prescribed medications. Obviously, this is part of this patient's history. And hypertensive urgency, the physical exam is within normal limits with certain exceptions, and the patient feels well. Indeed, I've seen patients like this with the blood pressure elevated. Again, I think my blood pressure went up a little bit with just examining them. But what's my role as an NP? What's your role as an NP? What's your role in passing boards? You have to apply best evidence and not push the clinical panic button.
The term hypertensive urgency, I do think rather implies that you have to do something really urgently, but that's not how this is defined by the American Heart Association, the American College of Cardiology. Another term for hypertensive urgency is severe asymptomatic hypertension. Now, I hesitate to even tell you that alternate term, because what do I think you're going to find on boards? The more common term: hypertensive urgency.
Keeping all that in mind, let's revisit the question in possible responses.
A 56-year-old man with a 10-year history of hypertension presents for a primary care visit, stating has not taken his high blood pressure medicines, which include a calcium channel blocker, an angiotensin-converting enzyme inhibitor, and thiazide diuretic for the past three months due to “running out of the medication and not getting to the pharmacy.” Today his BP is 192/120, and he’s without complaint, denying shortness of breath, chest pain, or visual changes. He states, “I just came in today for a visit since I ran out of my high blood pressure refills. I need to get back to work in a half an hour.” His physical exam is normal, with the exception of which of the following?
An S4 heart sound. Well, that's actually our correct answer. In hypertensive urgency, the S4 heart sound is an anticipated finding. This heart sound develops as a result of longstanding diastolic dysfunction, but without an issue in systolic dysfunction. And the S4 is usually heard with preserved cardiac output. And why does S4 heart sound develop? Because of the heart pumping blood out against a sustained elevated high blood pressure. Given that the patient's been off his high blood pressure meds for months, requires three high blood pressure meds for control, likely the blood pressure has been elevated for a protracted period. This S4 heart sound will resolve after the blood pressure has been in an acceptable range for probably a number of weeks, and the heart workload and stress is therefore improved. The S4 heart sound is an anticipated finding in hypertensive urgency.
Would it be B. Grade 3 hypertensive retinopathy? This is incorrect. Grade 3 hypertensive retinopathy findings include retinal hemorrhages as well as severe vasoconstriction in the retinal vessels. This is considered to be a finding that is part of hypertensive emergency, a condition where the blood pressure is markedly elevated, and the patient has signs and symptoms of hypertensive TOD. The person with high-grade hypertensive retinopathy, so grade 3, grade 4 are considered high grade, grade 1, grade 2 are low-grade hypertensive retinopathy. A person with high-grade hypertensive retinopathy reports altered vision in particular scotoma or black or blind spots in the visual field.
Well, we're informed in this situation that the patient doesn't have any visual changes. We're also told that his physical exam is within normal limits. So, if it says physical exam within normal limits, and this is markedly elevated blood pressure scenario, the back of the eyes should have been looked at, and therefore there is no evidence of bleeding into the back of the eye. Grade 3 hypertensive retinopathy is clearly pathologic, and aside from the visual changes expected to be reported, the patient would also have cardiac symptoms, and I'll expand on that with the next answer.
C. Neck vein distension. This is also incorrect, given that one of the hypertensive TODs is the heart, neck vein distension is usually noted in heart failure, and this is actually often seen with hypertensive emergency, but not urgency. Aside from this pathologic finding, likely the patient would report shortness of breath and or chest pain. Additional findings would include crackles in the lung fields, resting tachycardia, and other findings that are common in heart failure.
What are we told in this scenario? He feels okay, and oh, by the way, he would like you to just move this visit ahead because he's got to get back to work within the next half hour. And if you think people like this do not show up in primary care, think again. This happens on a regular basis.
So just to kind of wrap up this part, the high-grade hypertensive retinopathy, bleeding in the back of the eye, that's what we're thinking of. And if the vessels in the back of the eye are that stressed that they're bleeding, what do you think the vessels in the brain, the heart, and the kidneys look like? They’re similarly in a dysfunctional state. So that's why with very high-grade hypertensive retinopathy, you'll often have evidence of accelerated TOD in the heart and the kidneys.
Last option D. Murmur of aortic regurgitation. Clearly, this is incorrect. The murmur of aortic recurred is caused by the failure of the aortic valve leaflets to close properly. It's heard during diastole. So, remember diastole is between S2 and the next S1. While a variety of clinical conditions result in this murmur, including rheumatic heart disease, and tertiary syphilis, as well as bacterial endocarditis. This is not a common finding in either hypertensive urgency or emergency.
Key takeaways: Hypertensive urgency is a common condition noted in both primary and urgent care. Knowing how to differentiate urgency from emergency is key to safe and effective practice. And I'm going to review the treatment of hypertensive urgency in another podcast.
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