Question

A 56 year old male with hypertension and history of drug abuse and medication noncompliance presents to the clinic for follow up. He has been feeling well since his last appointment several months ago, but does admit to cocaine use last night when he ran into some old friends. He denies any other drug use. Medications include hydrochlorothiazide, atenolol, and paroxetine. Vital signs are temperature 36.9 C (98.4 F), pulse 85, blood pressure 202/122, and respirations 14/min. Physical examination reveals a comfortable, pleasant male in no distress. There is no papilledema or retinal hemorrhage on fundoscopic exam. The patient is alert, oriented, and neurologically intact. Laboratory evaluation, including CBC, electrolytes, BUN and creatinine, and urinalysis are all unremarkable. Which of the following is the most appropriate next step in the management of this patient?

A. Obtain urine drug screen
B. Head CT without contrast
C. Administer naloxone
D. Administer oral labetalol
E. Administer intravenous nitroprusside

Answer 1

The most appropriate next step is to administer oral labetalol (Option D), as it is effective in managing cocaine-induced hypertension and can help lower the patient's significantly elevated blood pressure safely and promptly.

Step-by-step explanation:

The patient in the scenario is presenting with signs of hypertensive emergency as evidenced by a blood pressure of 202/122. Immediate management is crucial to prevent end-organ damage. Since the patient admits to recent cocaine use, which is known to cause acute elevations in blood pressure and vasoconstriction, the most appropriate next step in management is to lower the blood pressure in a controlled manner. Option D, administering oral labetalol, is a suitable approach in this setting. Labetalol is a non-selective beta-blocker with alpha-blocking effects, making it especially useful in the context of cocaine-induced hypertension, as it can counteract the increase in sympathetic outflow triggered by cocaine use. A urine drug screen (Option A) might be helpful in confirming the substance abuse but does not address the immediate concern of elevated blood pressure. A head CT (Option B) would be more appropriate if there were signs of neurological involvement, while naloxone (Option C) is used to reverse opioid overdose, not cocaine intoxication. Intravenous nitroprusside (Option E) can be considered if there are signs of acute target organ damage or if the patient does not respond to oral agents and requires immediate blood pressure reduction in an intensive care setting.