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A 52-Year-Old Man With Sudden Dyspnea, Chest Pain, and Seizure

      A 52-year-old man presented to an outside hospital with confusion and chest discomfort. On arrival to the ED, he had a seizure (heart rate, 134 beats/min; BP, 300/180 mm Hg). BP was controlled with esmolol infusion, and benzodiazepines were given for the seizure. He underwent endotracheal intubation for airway protection and was transferred to our institution for further management. A chest radiograph showed perihilar infiltrates and increased vascular markings. Bilateral B-lines were visualized on bedside lung ultrasound scanning. CT angiograms of the head, neck, and chest were all unremarkable, except for bilateral opacities in the lungs. An EEG and MRI of the head did not reveal any intracranial pathologic condition. A formal transthoracic echocardiogram was also performed. After hemodynamic stability and successful spontaneous awakening and breathing trials on day 1, the patient was extubated without immediate complications. Eight hours later, he suddenly experienced severe dyspnea, chest pain, and facial erythema. BP reached a maximum of 367/210 mm Hg with bradycardia of 40 beats/min and oxygen saturation of 60%. Emergent endotracheal intubation was performed. Chest radiography showed worsening pulmonary edema. ECG revealed ST elevation in anterior and T-wave inversion in lateral leads. Troponins were elevated, and an emergent cardiac catheterization was performed that showed mild nonobstructive disease that required no intervention. An extensive investigation for secondary hypertension returned normal. BP was managed with nitroglycerin infusion and IV labetalol. Serial point-of-care ultrasound scans (POCUS) of the heart were performed, and diuretics were administered. A gradual transition to oral antihypertensives that included beta-blockers and calcium channel blockers was completed over the next 6 days. He was successfully weaned off mechanical ventilation on day 6 and discharged to home on day 9.
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