Step 2

Cardiovascular 11

A 53-year-old man presents to the emergency department complaining of acute onset frontal headaches and intermittent dyspnea for the past day, along with long-term constipation associated with generalized abdominal pain. The patient reports a history of methamphetamine use and migraines. He states he does not have a primary care physician, and he does not take any medications. He reports he last used a large dose of methamphetamine yesterday. He denies dizziness, lightheadedness, blurry vision, change in hearing, neck pain, back pain, diaphoresis, chest pain, palpitations, orthopnea, trouble with urination, or change in bowel movement. His vital signs include blood pressure 230/119 mmHg, heart rate 132 beats/min, and respirations 28/min with oxygen saturation 99% on room air. On physical examination, the patient appears cachectic, anxious, and restless. He is tachypneic and tachycardic, but there are no other significant exam findings.

  • Laboratory findings as below:
  • Hemoglobin 12.8 g/dL, MCV 79
  • Platelets 389,000 mcl
  • Sodium 140 mEq/L
  • Potassium 4.8 mEq/L
  • BUN 32 mg/dL
  • Creatinine 2.3 mg/dL
  • Troponin 0.23 ng/ml
  • Creatine Kinase 1499 U/L

Urinalysis shows proteinuria. Electrocardiogram shows sinus tachycardia. Chest X-ray shows cardiomegaly, no infiltrates, no pleural effusion. CT head shows no acute hemorrhage. CT of the abdomen and pelvis shows diverticulosis and moderate fecal impaction. Echocardiogram is pending a final read.

Which of the following is the most appropriate next step in management?

  • A) Administer benzodiazepine for methamphetamine intoxication and monitor
  • B) Admit to the intensive care unit and start intravenous antihypertensives to a target of 130/80 mmHg today
  • C) Admit to the intensive care unit and start intravenous antihypertensives to a target of 160/100 mmHg today
  • D) Bolus intravenous fluids immediately for rhabdomyolysis
  • E) Start the patient on amlodipine 10 mg orally daily and metoprolol 50 mg orally twice a day for hypertension and tachycardia

Authors

Yunjia Shen

Editor

Dr. Raj Dasgupta

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