David Tanaka is a 46 year old gentleman who came to the emergency room with a 4 day history of severe headaches. He is assessed and found to have a blood pressure of 240/160. He is placed on a cardiac monitor and intravenous labetolol is initiated. Clinical exam also shows retinal haemorrhages and exudates. He has numerous telangectasias across his face and chest. He also has thickening of the skin of his fingers (sclerodactyly). His initial bloodwork shows a serum creatinine of 240 umol/. His haemoglobin is reduced at 110 g/L, and a blood smear shows fragmented red blood cells consistent with intravascular hemolysis. Urinalysis shows 1+ protein and a trace of red cells. David is admitted to hospital.