hypertension crisis 5 DIAGNOSIS

Knowing the previous history and clinical findings are very important to distinguish between hypertension and hypertensive emergency urgency. Information about previous history of hypertension should include that have been diagnosed, the duration, degree, and control of blood pressure taken. Also find information about the previous history should take precedence in the discovery of the organ - the target organ affected, the situation during hypertension, and findings - that there are other findings.
Some other things that can be asked related to the occurrence of hypertensive crisis:
 Drugs - drugs
- Antihypertensive therapy previously obtained.
- The use of substances - substances "over - the - counter", as an example of a drug - a drug simpatomimetik.
- The use of drugs - drugs such as cocaine.
 Date of last menstrual
 other health problems (ex: hipertens earlier, thyroid disease, Cushing's syndrome, systemic lupus, and kidney disease).
 assessment of complaints that lead to hypertension crisis clinical findings:
-  chest pain of ischemic heart muscle or myocardium
- Back pain  aortic dissection
- Difficulty in breathing  pulmonary edema or congestive heart failure
- Symptoms - anxiety symptoms  neurologist, vision problems, level of chaos that changes - change (hypertension enselopati)
Physical examination should be given priority on things - things that can explain the crisis of hypertension in the emergency situation.
 Alerts - vital signs
 blood pressure should be measured in standing and sitting position (if possible  assess whether or not the volume depletion
 blood pressure should also be measured on both arms  significant differences leading to the aortic dissection.
Funduskopi examination may include changes that are consistent from chronic hypertension. Acute changes include arterial spasm (focal or diffus), retinal edema, bleeding in the retina (surface and shape as a tongue of fire, or deep and wide), exudate in the retina (hard or like cotton wool), or papiledema.
Examination focused on the cardiovascular whether there is a sign - a sign of heart failure (such as the lungs ronkhi voice, increased jugular venous pressure, askultasi emergence of S3 in the heart, and peripheral edema) or aortic dissection. Results further possibility of compensation can occur from an artery that is usually caused by a decrease in pulse rate, and this may result in ischemic brain, muscles, or digestive tract. Additional sound new murmur or mitral insufficiency penigkatan than may sound as a result of increased left ventricular afterload.
With the heart - the heart, neurological examination can directly explain the sign - a sign that will soon happen / is happening. Symptoms often arise as a result of hypertension among other enselopati, disorientation, decreased level of consciousness, and in some cases focal neurological deficit or seizures comprehensive or specific focal only. Enselopati hypertension is a stand-alone diagnosis, where the existence of other lesions (cont: stroke, subarachnoid hemorrhage, mass lesions) could be set aside. This is possible because of cerebral edema caused by the loss of autoregulation of cerebral blood vessels that appear because of hypertension weight.
The laboratory should be done immediately upon discovery of clinical symptoms and explain the important results for the ongoing situation. Routine blood tests can determine the presence or absence of mikroangiopati hemolytic anemia. Examination of urine can also indicate a hematuri, proteinuri or sediment on the state azotermia or kidney failure. Urine examination to determine the levels metanefrin can also be done to eliminate the possibility of pheokromositoma. Increased levels of serum urea and creatinine, metabolic acidosis, and hypokalemia can be seen on the blood chemistry tests which can indicate a decrease in kidney function. Aldosterone levels and plasma rennin can also be examined to rule out the existence of primary hiperaldosteronism in patients with significant hypokalemia previously not received diuretic drugs at the time of attack .. Hypokalemia which is the description of secondary aldosteronism, is at approximately 50% of patients with hypertensive crisis. In patients with elevated blood pressure due to natriuresis, serum sodium levels are usually lower than the state of primary aldosteronism. This happens because the increase in hydrostatic pressure peritubuler kidney-related increase in arterial pressure. This Natriuresis causes a secondary decrease in sodium reabsorbsi. Laboratory tests that can be done as an alternative to support the diagnosis of hypertensive crisis, among others, toxicology tests, pregnancy testing, and endocrine examinations.
Hipertropi the left ventricle and changes associated with ischemia or infarction can be seen on electrocardiography examination. Photo roentgens thoracic show evidence of heart enlargement, pulmonary edema, or a widened mediastinum, where it all can lead to aortic dissection. In addition, to further strengthen the suspicion of aortic dissection, can be performed chest CT examination, transesofageal ekhokardiografi, or with aortic arteriogram. Ekhokardiografi two dimensions can be used to distinguish pure diastole dysfunction of the heart during systole dysfunction sign - a sign of heart failure appear. All this may help in determining the therapy given and the provision of long-term therapy.
Head CT scan can be performed on patients with symptoms of neurological disorders. Sign - a sign that may arise from this investigation, among others, brain hemorrhage, brain edema, or ischemia in the brain.
In the end, it is important to determine the cause of secondary hypertension (eg hypertension renovaskular) which may cause the crisis. Test with a single dose of captopril may be given, especially in patients who did not receive drug therapy for hypertension before. Aktvitas levels of plasma rennin known in advance and then the patients were given 25 to 50 mg of captopril, 60 minutes and then re-examined rennin levels. The sensitivity value is a good test, but for very low spesifisitasnya. For further examination, such as Doppler ultrasound, MRI renal angiography, angiography with contrast, may be done to better diagnosis.
Using Skrening captopril test for secondary causes of the crisis of hypertension:
METHOD
o Patients receive adequate intake of salt and not getting a diuretic drug.
o Stop all hypertension medications three weeks before the test, if possible.
o The patient is seated at least 30 minutes, take blood samples and determined aktvitas levels of plasma rennin.
o captopril 50 mg diluted in 10 ml of water, the patient should immediately take the solution.
o After 60 minutes, take back the blood sample and measured re-elevated levels of plasma rennin.
INTERPRETATION
Expressed a positive test if:
 There was elevated levels of plasma rennin or more 12 ng/ml/jam.
and
 absolute increase in plasma rennin levels of 10 ng / ml / hour or more.
and
 Increased levels of plasma rennin > 150 % or > 400 % if the lower threshold value of plasma rennin levels were < 3 ng / ml / days.