What is the appropriate emergency department assessment and management plan for a 76‑year‑old woman with hypertension and dyslipidemia who presents with severe hypertension, non‑rotatory dizziness, dry heaving, normal neurological exam except unstable tandem gait, and no focal deficits?

Assessment and Plan for 76-Year-Old Woman with Severe Hypertension and Non-Rotatory Dizziness

Immediate Classification: Hypertensive Urgency vs. Emergency

This patient most likely has hypertensive urgency, NOT a hypertensive emergency, based on the absence of acute target-organ damage on initial evaluation. 1

The critical distinction is not the blood pressure value (185/90 mmHg) but whether acute organ damage is present. 1 Her BP elevation is significant but does not meet the threshold (≥180/120 mmHg) typically defining hypertensive crisis, and more importantly, her focused examination shows no evidence of acute neurologic, cardiac, renal, or ophthalmologic injury. 1

However, the unstable tandem gait is a red flag that mandates urgent neurologic evaluation before definitively classifying this as urgency. 2 Tandem gait instability can represent subtle cerebellar or posterior-circulation involvement that may herald hypertensive encephalopathy or acute stroke. 2

Mandatory Immediate Workup in the Emergency Department

Essential Laboratory Studies (Draw Immediately)

• Complete blood count (hemoglobin, platelets) to assess for microangiopathic hemolytic anemia suggesting thrombotic microangiopathy 1
• Basic metabolic panel (creatinine, sodium, potassium) to evaluate renal function and detect acute kidney injury 1
• Lactate dehydrogenase and haptoglobin to detect hemolysis in hypertensive thrombotic microangiopathy 1
• Urinalysis with microscopy for protein, red blood cells, white blood cells, and casts to identify renal damage 1
• Troponin if any chest discomfort is present to evaluate for acute coronary syndrome 1
• Electrocardiogram to assess for cardiac involvement 1

Critical Physical Examination Components

• Dilated fundoscopy is mandatory—look specifically for bilateral retinal hemorrhages, cotton-wool spots, or papilledema (grade III-IV retinopathy) that would define malignant hypertension and reclassify this as an emergency 1, 2
• Detailed neurologic examination focusing on mental status, visual fields, cranial nerves, cerebellar function (finger-to-nose, heel-to-shin, Romberg), and gait stability to detect subtle signs of hypertensive encephalopathy or posterior-circulation ischemia 2
• Cardiovascular examination for signs of acute heart failure (pulmonary edema, elevated JVP, S3 gallop) 1

Neuroimaging Decision

Given the unstable tandem gait, obtain urgent non-contrast head CT immediately to exclude acute stroke, intracranial hemorrhage, or posterior-circulation pathology. 2 If CT is negative but clinical suspicion remains high, MRI brain with contrast is superior for detecting posterior reversible encephalopathy syndrome (PRES) and subtle cerebellar or brainstem lesions. 2

Management Algorithm

If Acute Target-Organ Damage is Identified (Hypertensive Emergency)

Admit to ICU immediately with continuous arterial-line monitoring (Class I recommendation). 1

Blood pressure targets:

• Reduce mean arterial pressure by 20-25% within the first hour 1
• Then lower to ≤160/100 mmHg over 2-6 hours if stable 1
• Gradually normalize over 24-48 hours 1
• Never drop systolic BP >70 mmHg acutely—this can precipitate cerebral, renal, or coronary ischemia in chronic hypertensives with altered autoregulation 1

First-line IV medication:

• Nicardipine 5 mg/h IV infusion, titrate by 2.5 mg/h every 15 minutes to maximum 15 mg/h 1
  • Preferred because it preserves cerebral blood flow, does not raise intracranial pressure, and allows predictable titration 1
  • Particularly appropriate if hypertensive encephalopathy is confirmed 2
• Alternative: Labetalol 10-20 mg IV bolus over 1-2 minutes, repeat/double every 10 minutes (max cumulative 300 mg) 1, 3
  • Contraindicated if patient has reactive airway disease, COPD, heart block, bradycardia, or decompensated heart failure 1, 3

If NO Acute Target-Organ Damage is Found (Hypertensive Urgency)

Do NOT admit to hospital; manage with oral medications and outpatient follow-up. 1

Blood pressure targets:

• Gradual reduction to <160/100 mmHg over 24-48 hours 1
• Then achieve <130/80 mmHg over subsequent weeks 1
• Avoid rapid BP lowering—this can cause cerebral, renal, or coronary ischemia in chronic hypertensives 1

Oral medication options:

• Restart/optimize her home amlodipine 5 mg daily and consider increasing to 10 mg daily 1
• Add or increase atorvastatin (already on 20 mg) for cardiovascular risk reduction 1
• Consider adding low-dose ACE inhibitor (e.g., lisinopril 5-10 mg daily) or ARB if not contraindicated 1
• Extended-release nifedipine 30-60 mg PO is an alternative if additional calcium channel blockade is needed 1
• NEVER use immediate-release nifedipine—it causes unpredictable precipitous drops, stroke, and death 1

Observation period:

• Observe in ED for at least 2 hours after medication administration to assess response and safety 1
• Recheck BP before discharge to ensure it is trending downward 1

Discharge instructions:

• Arrange outpatient follow-up within 2-4 weeks 1
• Emphasize medication adherence—non-adherence is the most common trigger for hypertensive crises 1
• Instruct patient to return immediately if she develops severe headache with vomiting, altered mental status, visual loss, chest pain, severe dyspnea, focal neurologic deficits, or seizures 1

Critical Pitfalls to Avoid

• Do not dismiss the unstable tandem gait as "benign dizziness"—this represents a neurologic symptom that significantly increases the likelihood of intracranial pathology 2
• Do not rely solely on the normal neurologic exam—absence of focal deficits does not exclude hypertensive encephalopathy, PRES, or early stroke 2
• Do not delay neuroimaging while attempting BP reduction—identifying underlying pathology guides appropriate BP targets and treatment intensity 2
• Do not rapidly normalize BP in this chronic hypertensive patient—her cerebral autoregulation is altered and acute normalization can cause ischemic injury 1
• Do not assume absence of symptoms equals absence of organ damage—fundoscopy and laboratory studies are essential 1
• Do not use IV antihypertensives if this is confirmed as urgency—oral therapy is safer and appropriate 1

Post-Stabilization Considerations

• Screen for secondary hypertension after stabilization—20-40% of malignant hypertension cases have identifiable causes (renal artery stenosis, pheochromocytoma, primary aldosteronism, renal parenchymal disease) 1
• Address medication adherence—the patient took her amlodipine late (9:30 PM instead of morning), suggesting possible non-adherence 1
• Schedule monthly follow-up until target BP <130/80 mmHg is achieved 1
• Recognize prognostic implications—without treatment, hypertensive emergencies have >79% one-year mortality, but with appropriate management, survival has improved significantly 1, 2