Definitions and Terminologies

Hypertension is a chronic condition,resulting in target

organ damage over years.However it is possible for the
Blood pressure to rise suddenly and severely to cause
acute damage to end organs.
Hypertensve crisis refers to such sudden critical
elevation in BP ,usually with a diastolic BP above 120
mm of Hg and the presence of ongoing or evolved
target organ dysfunction defines a Hypertensive
emergency, whereas the absence of such end organ
dysfunction is referred to as Hypertensive urgency. It
is important to recognize that rapidity of rise in BP is
more important than the actual numbers. Accelerated
malignant Hypertension is the term used to
describe severe hypertension with fundal changes of
retinal exudates, haemorrhages andpapilloedema.
Cerebral, renal and gastrointestinal features are often
seen during this malignant phase .
Chronic uncontrolled severe Hypertension needs
to be distinguished from Hypertensive Urgency wherein
the patient may or may not experience severe
headache, nose bleeds, or severe anxiety.The tempo of
the rise in BP may also aid in differentiation( sudden or
rapid rise in BP in Hypertensive urgencies).Similarly
Hypertensive Emergency requires to be recognized
separately from clinical situations in which patient has
elevated BP with target organ damage that is unrelated
to the High BP.
A 45 year old Lady presented to a NGO clinic offering free BP check up at a
Sunday market and her BP was found to be 200/120 mm of Hg. On further
questioning by the Doctor assisting the clinic, the lady was found to be a known
hypertensive diagnosed two years ago and she has stopped taking taking
medications for the last six months since she felt well.She felt that marketting for

more than an hour in the busy market that morning could have been the reason
for the high BP.Quick examination of fundus revealed arteriosclerotic changes in
retinal vessels ( Grade 2 KWP )

1) Which of the following statements are true in relation to her condition ?

Select one or more:
A. She is suffering from a Hypertensive Urgency
B. She is suffering from Accelerated- malignant hypertension
C. She has only severe uncontrolled Hypertension
D. Her BP reduction needs parentral anti hypertensive medications
E. Her BP can be reduced gradually over a period of days with oral anti
hypertensive medications
2) Which of the following situations constitutes Hypertensive crises ?
Select one or more:
A. Perioperative states Correct
B. Pre eclampsia and Eclampsia Correct
C. Cocaine and amphetamine substance abuse Correct
D. Steroid therapy in Scleroderma Correct
E. Guillain Barre syndrome Correct

55 year old lady ,diagnosed to have hypertension for 5 years,was seen in the AE
with 3 day history of nausea,vomitting, headache and dizziness.Her BP was
found to be 220/140 mm of Hg.She was drowsy and her fundoscpic examination
revealed exudates, haemorrhages and papilloedema.In the AE she suddenly
threw a generalised tonic clonic seizure.

3) Which of the following are true in relation to her condition ?

Select one or more:
A. This patient has intracerbral haemorrhage ( Hypertensive emergency)
B. She is suffering from Hypertensive encephalopathy Correct

C. Focal or lateralising Neurological defecits are common findings.

D. Fragmented red cells should be looked for in the peripheral blood film Correct
E. CT scan of the brain may show posterior leucoencephalopathy Correct

Which of the statements regarding the control of BP in this case are true?
Select one or more:
A. Blood pressure should be reduced to normal levels within minutes
B. Reduction of MAP by 25% over 2 to 8 hours is recommended. Correct
C. Gradual reduction of BP over a period of days(1 to 2) by oral therapy is
sufficient.
D. IV Nitroprusside infusion is safe and is the treatment of choice
E. Intravenous labetalol ,bolus or infusion, is recommended Correct

5) IV Sodium Nitroprusside
Select one or more:
A. is an arterial and veno vasodilator Correct
B. increases intracranial pressure Correct
C. Normal renal and liver functions are not necessary
D. Toxicity can result in serious neurologic problems Correct
E. cyano cobalamin is effective in preventing and treating toxicity Correct
48 year old lady , mother of three children, developed sudden severe headache
while washing clothes and vomitted a few times before collapsing on the
bathroom floor. On arrival at AE, she was stuporous, only responding to painful
stimulus. Her pulse was 94/mt,with a BP of 220/160 mm of Hg. Her respiration
was laborious and noisy and her pupils were unequal with left pupil in mid
position and her right pupil small and reacting to light. Her eyes were deviated to
the left side. Paucity of movements was noted on the right half of the body.
History from the husband revealed that patient was diagnosed to have high BP
2years ago and was not taking regular treatment. A 12 lead ECG done at AE
while waiting for the on call radiologist to do a CT brain showed deep and
symmetrically inverted T waves in precordial leads;
6) Which of the following statements are true in relation to her condition ?
Select one:

A. She has Hypertensive acute coronary syndrome

B. She had developed Hypertensive intracerebral bleed Correct
C. BP reduction should involve bringing down the MAP by 50% over an hour by
parentral anti hypertensive agents.
D. IV Nitroglycerine can be used safely
E. Nimodipine is the drug of choice
64 years old post master woke up from the sleep at 6 AM and noticed that he
was paralysed on his right half of the body.He was aphasic but fully conscious
and his BP was found to be elevated at 190/130 mm of Hg. A CT brain performed
at 8.30 AM revealed massive infarct in the Lt middle cerebral artery territory.

7) Which of the following statements are true in relation to his condition ?

Select one:
A. It is advisable to reduce MAP by 25% over 1 to 2 hours with parentral anti
hypertensives
B. It is recommended to reduce BP gradually over a period of 1 to 2 days with
oral antihypertensives
C. BP reduction should not be attempted with in the first Two weeks Correct
D. Thrombolytic therapy should be started immediately
E. Vasodilating anti hypertensive drugs should be used to reduce BP

52 years old man with Acute coronary syndrome, Acute LV failure and BP 0f
190/120
8) Which of the statements are true in the above situation ?
Select one or more:
A. Bring down the MAP by 25 % over a short period Correct
B. IV Nitroglycerine drip is a good initial choice. Correct
C. IV enalapril or oral captopril can be used Correct
D. IV furasemide is indicated. Correct
E. Labetalol is safe and beneficial in patients with ACS and High BP. Correct

10) Which of he following statements are true in relation to management of

Hypertensive crisis ?
Select one or more:
A. Vasodilating anti hypertensive agents include Nitroprusside, Nitroglycerine,
Hydralazine and Nicardipine
B. Labetalol and carvedelol are alpha and beta adrenergic blockers
C. Phentolamine is an alpha blocker and Esmolol is a beta blocker
D. Enalapril and captopril are agents that reduce preload.
E. Furasemide use is associated with no cardiovascula adverse effects