Provide an assessment, management plan, and concise HIMS order set for an adult patient with known hypertension on losartan 100 mg daily who presents with severe hypertension (BP 180/100 mmHg) and light‑headedness but no signs of end‑organ damage.

Assessment and Management Plan

Assessment

This patient presents with a hypertensive urgency, NOT a hypertensive emergency. Despite a blood pressure of 180/100 mmHg, there is no evidence of acute target‑organ damage on comprehensive neurologic, cardiac, renal, or ophthalmologic examination. 1, 2

Key Clinical Findings:

• Blood pressure: 180/100 mmHg (Stage 2 hypertension, very high BP)
• Symptoms: Lightheadedness and dizziness (non-specific, not indicating end-organ damage)
• Neurologic exam: Completely normal (GCS 15, intact cranial nerves, no focal deficits, normal cerebellar function, 5/5 strength bilaterally, intact sensation)
• Cardiac exam: Regular rhythm, no murmurs, no signs of acute heart failure
• No evidence of: Hypertensive encephalopathy, stroke, acute coronary syndrome, pulmonary edema, acute kidney injury, or malignant hypertensive retinopathy
• Current medication: Losartan 100 mg daily (50 mg BID), which represents adequate dosing 1

Classification Rationale:

The absence of acute target‑organ damage is the critical distinguishing feature between hypertensive emergency and urgency—not the absolute blood pressure number. 1, 2 This patient requires outpatient management with oral medications, not ICU admission or IV therapy. 1, 2

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Management Plan

Immediate Management (Emergency Department/Clinic)

1. Optimize Current Losartan Regimen

• The patient is already on losartan 100 mg daily (maximum recommended dose), which has proven efficacy in severe hypertension. 3
• Add hydrochlorothiazide 12.5 mg once daily to the existing losartan regimen, as the combination produces significant additional antihypertensive response. 1, 4
• This combination (losartan/HCTZ) has been shown to reduce sitting DBP by 13.7 mmHg and sitting SBP by 19.3 mmHg in patients with uncontrolled hypertension. 4

2. Blood Pressure Reduction Strategy

• Target: Gradual reduction to <160/100 mmHg over 24–48 hours, then normalize to <130/80 mmHg over the following weeks. 1, 2
• Avoid rapid lowering: Do NOT attempt to normalize blood pressure acutely, as this may cause cerebral, renal, or coronary ischemia in patients with chronic hypertension who have altered autoregulation. 1, 2
• Rapid BP lowering in asymptomatic patients may be harmful. 2

3. Observation Period

• Observe the patient for at least 2 hours after medication administration to assess efficacy and safety. 2
• Recheck blood pressure before discharge to ensure no excessive drop has occurred. 2

4. Address Medication Adherence

• Medication non‑adherence is the most common trigger for hypertensive emergencies and urgencies. 2
• Counsel the patient on the importance of taking losartan consistently at the prescribed times (morning and evening doses). 1
• Discuss barriers to adherence and provide strategies to improve compliance. 2

Follow-Up Plan

1. Short-Term Follow-Up

• Schedule outpatient visit within 2–4 weeks to assess response to therapy. 1, 2
• At this visit, check blood pressure and assess for orthostatic hypotension. 1

2. Medication Titration Strategy

• If BP remains >130/80 mmHg after 2–4 weeks on losartan 100 mg + HCTZ 12.5 mg:
  • Increase HCTZ to 25 mg once daily. 1, 4, 3
• If BP still not controlled after maximizing losartan/HCTZ:
  • Add a dihydropyridine calcium channel blocker (e.g., amlodipine 5–10 mg once daily). 1, 3
• If triple therapy is insufficient:
  • Consider adding atenolol 50–100 mg once daily. 1, 3

3. Long-Term Monitoring

• Monthly follow-up visits until target BP <130/80 mmHg is achieved. 1, 2
• Monitor for electrolytes and renal function 2–4 weeks after initiating or adjusting diuretic therapy. 1
• Screen for secondary causes of hypertension if BP remains uncontrolled despite triple therapy, as 20–40% of malignant hypertension cases have identifiable causes (renal artery stenosis, pheochromocytoma, primary aldosteronism). 2

Patient Education

1. Lifestyle Modifications

• Reinforce the importance of nonpharmacological therapy: sodium restriction, weight loss if overweight, regular physical activity, moderation of alcohol intake. 1
• Limit alcohol consumption (currently 4–5 bottles per month is acceptable, but should not increase). 1

2. Symptom Monitoring

• Instruct the patient to return immediately if any of the following develop:
  • Severe headache with vomiting
  • Altered mental status or confusion
  • Visual disturbances or vision loss
  • Chest pain or severe dyspnea
  • Focal neurologic deficits (weakness, numbness, slurred speech)
  • Seizures
• These symptoms would indicate progression to hypertensive emergency requiring immediate ICU admission. 1, 2

3. Home Blood Pressure Monitoring

• Encourage home BP monitoring to detect white coat effect and assess response to therapy. 1
• Target home BP <130/80 mmHg. 1

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Critical Pitfalls to Avoid

• Do NOT admit this patient to the hospital or ICU, as there is no evidence of acute target‑organ damage. 1, 2
• Do NOT use IV antihypertensive medications for hypertensive urgency; oral therapy is appropriate. 1, 2
• Do NOT rapidly lower blood pressure in this asymptomatic patient, as it may cause cerebral, renal, or coronary ischemia. 1, 2
• Do NOT use immediate‑release nifedipine, as it can cause unpredictable precipitous BP drops, stroke, and death. 2
• Do NOT dismiss the patient's lightheadedness and dizziness as insignificant; these symptoms may represent orthostatic hypotension from the recent losartan dose or may indicate early organ hypoperfusion. Assess orthostatic vital signs. 1

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HIMS Order Set (Concise Format)

Diagnosis

• Hypertensive urgency (Stage 2 hypertension, very high BP)
• Essential hypertension, uncontrolled

Disposition

• Discharge home with outpatient follow-up

Medications

1. Losartan 50 mg PO BID (continue current regimen)
2. Hydrochlorothiazide 12.5 mg PO once daily (NEW)
   • Take in the morning to avoid nocturia
3. Acetaminophen 500 mg PO PRN for headache (if needed)

Laboratory Orders

• Basic metabolic panel (BMP) – to assess baseline renal function and electrolytes before starting HCTZ
• Urinalysis – to screen for proteinuria (target organ damage)
• ECG – to assess for left ventricular hypertrophy

Monitoring

• Vital signs: Blood pressure, heart rate every 30 minutes × 2 hours
• Orthostatic vital signs before discharge
• Recheck BP before discharge to ensure no excessive drop

Follow-Up

• Outpatient appointment in 2 weeks with primary care provider
• Repeat BMP in 2–4 weeks after starting HCTZ to monitor electrolytes and renal function

Patient Education

• Medication adherence counseling
• Lifestyle modifications: sodium restriction, weight management, regular exercise, alcohol moderation
• Home BP monitoring instructions
• Return precautions: severe headache, visual changes, chest pain, dyspnea, altered mental status, focal neurologic deficits

Discharge Criteria

• BP <160/100 mmHg after observation period
• No orthostatic hypotension
• Patient understands discharge instructions and follow-up plan