A 36-year-old man presents to urgent care with a chief complaint of wrist pain after a sports injury. His blood pressure at triage is 224/118 mm Hg, with a repeat measurement of 221/117 mm Hg taken on the opposite arm a few minutes later. He reports having a severe headache that started about 2 hours ago, which he rates as 9/10 in intensity. He also mentions that his vision seems “blurry.” On physical examination, you note that he appears uncomfortable and is having difficulty providing a clear history due to altered mental status. Fundoscopic examination reveals bilateral papilledema and retinal hemorrhages.
What is this patient’s condition and what are the most appropriate next steps?
- Hypertensive emergency; transfer to the emergency department for parenteral therapy and admission to a monitored setting
- Severe hypertension; discharge with oral antihypertensive medication and primary care follow-up in 1 week
- Severe hypertension with anxiety due to pain; provide reassurance and pain management for the wrist injury, which should reduce the blood pressure
- Stage 2 hypertension; initiate oral lisinopril in urgent care and observe for 2 hours before discharge
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Correct Answer: a. Hypertensive emergency; transfer to the emergency department for parenteral therapy and admission to a monitored setting.
This patient has a hypertensive emergency, defined as blood pressure >180/120 mm Hg with evidence of acute end-organ damage. The presence of severe headache, visual changes, altered mental status, papilledema, and retinal hemorrhages indicates acute target-organ damage affecting multiple systems (brain and retina). According to the 2025 AHA/ACC guidelines on the evaluation and management of high blood pressure, patients with hypertensive emergency should be transferred to the emergency department for parenteral antihypertensive therapy and admission to a monitored setting. Discharge from urgent care would be inappropriate and potentially dangerous for this patient.
After recognizing this patient’s hypertensive emergency, you immediately contacted emergency medical services while maintaining the patient in a calm, quiet environment. You explained to the patient that his severely elevated blood pressure, combined with concerning symptoms, indicated a medical emergency requiring immediate transfer to the hospital for specialized treatment. You advised the emergency department team of the patient’s presentation, including his blood pressure readings and signs of end-organ damage. The patient was transported via ambulance to the emergency department, where he was admitted to the intensive care unit for continuous monitoring and parenteral antihypertensive therapy. You documented your findings thoroughly and followed up with the receiving team to ensure continuity of care. The patient’s wrist injury, while his initial chief complaint, was appropriately triaged as a secondary concern given his life-threatening hypertensive emergency.
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Tracey Davidoff, MD, FACP, FCUCM, has practiced Urgent Care Medicine for more than 15 years. She is Board Certified in Internal Medicine. Dr. Davidoff is a member of the Board of Directors of the Urgent Care Association and serves as Co-Editor-in-Chief of the College of Urgent Care Medicine’s “Urgent Caring” publication. She is also the Vice President of the Southeast Regional Urgent Care Association and a member of the editorial board of the Journal of Urgent Care Medicine. At EB Medicine, Dr Davidoff is Editor-In-Chief of Evidence-Based Urgent Care, and co-host of the Urgentology podcast.
