A 59-year-old gentleman presents to the Emergency Department complaining of a headache. He has had similar headaches over the last few weeks and also some blurring of his vision. His initial observations are as follows: HR 92 bpm, BP 210/132 mmHg, SaO2 99% on air, BM 7.2, GCS 15/15.

1. What is the most likely diagnosis?
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The most likely diagnosis, in this case, is malignant hypertension (or accelerated hypertension).

Malignant hypertension is the presence of severe hypertension (BP >180/110) with evidence of end-organ damage.

2. What other features may be present on examination?
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Other examination features that may be present include the following:

  • A focal neurological deficit
  • Papilloedema
  • 3rd heart sound
  • Ankle oedema
  • Pulmonary oedema
  • Pallor (due to angiopathic haemolytic anaemia)
  • Presence of encephalopathy
3. How should this patient be treated?
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This situation requires immediate treatment to reduce the blood pressure steadily. Rapid BP drops should be avoided as this can result in stroke or myocardial infarction. Drugs that can be used are labetalol or nifedipine.