How should I assess and manage a previously untreated adult with severe hypertension (170/110 mmHg) presenting with orthostatic dizziness, retro‑orbital/frontotemporal headache, and dry heaving, but no signs of target‑organ injury?

Assessment and Plan for Severe Hypertension (170/110 mmHg) with Orthostatic Dizziness and Headache

Immediate Classification: Hypertensive Urgency vs. Emergency

This patient presents with hypertensive urgency, not a hypertensive emergency, and can be managed with oral antihypertensives and outpatient follow-up rather than hospital admission. 1, 2

The critical distinction depends on the presence or absence of acute target-organ damage—not the absolute blood pressure value. 1, 2 This patient's BP of 170/110 mmHg with orthostatic dizziness, headache (now 2/10), and dry heaving does not constitute acute target-organ damage. 2, 3

Rapid Assessment for Target-Organ Damage (Already Completed)

Your neurologic examination effectively rules out hypertensive encephalopathy:

• Neurologic: GCS 15, fully oriented, no altered mental status, no visual deficits, no focal deficits, intact cranial nerves, normal cerebellar function 2, 3
• Cardiac: No chest pain, no dyspnea, no pulmonary edema signs, regular rhythm without murmurs 2, 3
• Renal: No oliguria reported (though baseline creatinine needed) 2
• Ophthalmologic: Anicteric sclera noted, but fundoscopy is essential to exclude malignant hypertension (bilateral retinal hemorrhages, cotton-wool spots, papilledema) 2, 3

Why This is Urgency, Not Emergency

• Orthostatic dizziness likely reflects volume depletion from pressure natriuresis, not acute cerebrovascular injury 2
• Headache has improved from 5/10 to 2/10, inconsistent with hypertensive encephalopathy 2, 3
• Dry heaving without persistent vomiting does not indicate increased intracranial pressure 2
• Normal neurologic exam excludes stroke or encephalopathy 2, 3

Essential Diagnostic Workup Before Discharge

Laboratory Tests to Order Now

Complete the following panel to detect subclinical target-organ damage: 2, 4

• Basic metabolic panel (creatinine, sodium, potassium, glucose) to assess renal function and electrolytes 2, 4
• Complete blood count (hemoglobin, platelets) to screen for thrombotic microangiopathy 2, 4
• Urinalysis for proteinuria and hematuria 2, 4
• Electrocardiogram to detect left ventricular hypertrophy or ischemia 2, 4
• Troponin-I given the history of dry heaving and to exclude silent cardiac injury 2, 4

Rationale: Studies show 8.3% of patients with asymptomatic severe hypertension have new-onset end-organ damage, most commonly renal (73.3%) followed by cardiac (26.6%). 4 Patients over 60 years with diabetes, ischemic heart disease, or cerebrovascular accident history have significantly higher risk. 4

Fundoscopic Examination (Critical)

Perform dilated fundoscopy to look for bilateral retinal hemorrhages, cotton-wool spots, or papilledema (grade III-IV retinopathy). 2, 3 The presence of these findings would reclassify this as malignant hypertension requiring emergency management. 2

Pharmacologic Management Plan

Immediate Oral Antihypertensive Therapy

Initiate extended-release nifedipine 30 mg PO now as first-line therapy. 2, 5

Alternative options if nifedipine contraindicated:

• Captopril 12.5–25 mg PO (caution: may cause abrupt BP drop if volume-depleted from pressure natriuresis) 2
• Oral labetalol 200 mg PO (contraindicated if reactive airway disease, heart block, or bradycardia) 2

Never use immediate-release nifedipine—it causes unpredictable precipitous drops, stroke, and death. 2, 5

Blood Pressure Reduction Strategy

Target gradual reduction over 24–48 hours to <160/100 mmHg, then <130/80 mmHg over subsequent weeks. 1, 2, 6

• Do not rapidly lower BP in this patient—abrupt reductions can precipitate cerebral, renal, or coronary ischemia in chronic hypertensives with altered autoregulation. 1, 2, 6
• Observe for at least 2 hours after medication administration to assess efficacy and safety. 2

Long-Term Antihypertensive Regimen

Since the patient is on no maintenance medications despite a history of hypertension:

Start combination therapy:

• ACE inhibitor or ARB (e.g., losartan 50 mg daily, titrate to 100 mg) 1
• Add thiazide diuretic (hydrochlorothiazide 12.5 mg daily, increase to 25 mg if needed after 2–4 weeks) 1
• If BP remains >130/80 mmHg, add dihydropyridine calcium-channel blocker (amlodipine 5–10 mg daily) 1

Check basic metabolic panel 2–4 weeks after starting diuretic to monitor for electrolyte disturbances and renal function changes. 2

Risk Factor Modification & Lifestyle Interventions

Address modifiable risk factors immediately: 1

• Smoking cessation: Vaping 1 canister/month contributes to endothelial dysfunction and BP elevation 1
• Sodium restriction to <2 g/day 1
• Weight management if BMI elevated 1
• Alcohol moderation (currently occasional drinker—maintain moderation) 1
• Regular aerobic exercise 150 minutes/week 1

Follow-Up Plan

Schedule outpatient follow-up within 2–4 weeks to reassess BP control and review laboratory results. 1, 2

Monthly visits thereafter until target BP <130/80 mmHg is consistently achieved. 1, 2

Home blood pressure monitoring: Instruct patient to measure BP twice daily and maintain log; target home BP <130/80 mmHg. 2

Screening for Secondary Hypertension

After stabilization, screen for secondary causes given the patient's young age (BPO worker suggests <65 years), severe hypertension, and lack of prior treatment: 2, 7

• Renal artery stenosis (renal ultrasound with Doppler) 2, 7
• Primary aldosteronism (aldosterone-to-renin ratio) 2, 7
• Pheochromocytoma (24-hour urine metanephrines) 2, 7
• Renal parenchymal disease (already assessed via creatinine and urinalysis) 2, 7

Rationale: 20–40% of patients with malignant hypertension have identifiable secondary causes. 2, 7

Patient Education & Red-Flag Symptoms

Counsel the patient to return immediately to the emergency department if any of the following develop: 2, 3

• Severe headache with vomiting or altered mental status (hypertensive encephalopathy) 2, 3
• Visual loss or disturbances (cortical blindness, retinal damage) 2, 3
• Chest pain or severe dyspnea (acute coronary syndrome, pulmonary edema) 2, 3
• Focal neurologic deficits or seizures (stroke) 2, 3
• Sudden severe back or abdominal pain (aortic dissection) 2, 3

Emphasize medication adherence—non-adherence is the most common trigger for hypertensive emergencies. 2, 7

Critical Pitfalls to Avoid

• Do not admit this patient to the hospital or ICU—hypertensive urgency without target-organ damage is managed outpatient. 1, 2
• Do not use IV antihypertensives—oral therapy is appropriate for urgency. 1, 2
• Do not rapidly lower BP—up to one-third of patients with elevated BP normalize before follow-up, and rapid lowering may cause harm. 2, 5
• Do not discharge without fundoscopy—missing malignant hypertension would be a critical error. 2, 3
• Do not assume orthostatic dizziness is benign—it may indicate volume depletion from pressure natriuresis, requiring cautious use of ACE inhibitors. 2

Disposition

Discharge home with:

• Extended-release nifedipine 30 mg PO daily 2
• Outpatient follow-up in 2–4 weeks 1, 2
• Home BP monitoring instructions 2
• Written red-flag symptoms requiring immediate return 2, 3
• Laboratory results pending review at follow-up 2, 4