intense vasoconstriction, ischemia, and gangrene. 2) The most common reason for elevated blood pressure is noncompliance with medical therapy. Given this patient’s heart rate of 85, it is veryunlikely that he has taken a recent dose of his beta blocker. Obtaining a urine drug screen (answer A) will not help in the management of this patient. He has already admitted recent cocaine use,and there is not a compelling reason to immediately search out any other drugs of abuse in his system. While in some cases it may be beneficial to have some laboratory documentation of thispatient’s drug use, confirming that he has used cocaine is not the top priority at this point given this patient’s markedly elevated blood pressure. As a sidenote, remember that patients on theUSMLE don’t lie – in sharp contrast to real patients, you can take their assessment of substance use at face value unless the question stem give you obvious reason to doubt it. A head CTwithout contrast (answer B) is the test of choice for diagnosing an acute head bleed. In a patient with malignant hypertension, you might also discover lacunar infarcts. This patient has nosymptoms, though, so this test is unnecessary at this point. Naloxone (answer C) is an opioid antagonist. It may be useful in a patient who has overdosed on opiates, but it has no role inhypertensive urgency or cocaine intoxication. Administering intravenous nitroprusside (answer E) will bring the patient’s blood pressure down, but will require an inpatient (or potentially even anICU) admission for blood pressure monitoring. If this patient were having symptoms – that is, if he were having a hypertensive emergency rather than hypertensive urgency – this would be anappropriate management plan, but in the absence of symptoms, it is a bit too much at the present moment.E.Administering intravenous nitroprusside (answer E) will bring the patient’s blood pressure down, but will require an inpatient (or potentially even an ICU) admission for blood pressure monitoring.If this patient were having symptoms – that is, if he were having a hypertensive emergency rather than hypertensive urgency – this would be an appropriate management plan, but in the absenceof symptoms, it is a bit too much at the present moment.This question is not currently linked to the learning objective database.Question problem?
