A 58-year-old man with long-standing uncontrolled hypertension presents with BP 230/130 mmHg, severe headache, altered consciousness, bilateral papilledema, and serum creatinine 3.2 mg/dL (baseline 1.1 mg/dL). Urinalysis shows proteinuria and microscopic hematuria. This represents:

• A Hypertensive urgency — outpatient oral antihypertensive therapy
• B Grade 3 hypertension — start dual oral therapy immediately
• C Secondary hypertension workup before any treatment
• D Hypertensive emergency (malignant hypertension) with end-organ damage — IV antihypertensive therapy ✓

Explanation

This patient has a hypertensive emergency — severely elevated BP with acute end-organ damage: hypertensive encephalopathy (headache, altered consciousness), grade IV retinopathy (papilledema), and acute kidney injury. Treatment requires IV antihypertensives with careful, controlled BP reduction (reduce MAP by 20-25% in the first hour, then target ~160/100 mmHg in 2-6 hours). Preferred agents: labetalol, nicardipine, or sodium nitroprusside. In hypertensive urgency (severely elevated BP without end-organ damage), oral therapy with short-acting agents over 24-48 hours is appropriate. Delaying treatment for secondary workup is inappropriate given active end-organ damage.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.