GIM Question 6 Instructor

A patient on your ward complains of feeling “unwell” while you are on call in the middle of the night. Vital signs are as follows: HR 120, BP 210/115 (baseline BP is 140/85), RR 18, SpO2 98% on room air, T 37.2 (oral).

  1. What is the definition of a “Hypertensive Emergency?”

    The definition of Hypertensive Emergency includes:

    • Asymptomatic diastolic BP ≥ 130
    • Hypertension with acute end organ damage:
      • Hypertensive encephalopathy
      • Acute aortic dissection
      • Acute left ventricular failure
      • Acute coronary syndrome
      • Acute kidney injury
      • Intracranial haemorrhage
      • Acute ischemic stroke
      • Preeclampsia/eclampsia (pregnancy after 20 weeks and up to six weeks postpartum).

      A sudden change in blood pressure above SBP>180 and/or DBP>120, with or without symptoms, should warrant an investigation into end organ damage.

  2. What symptoms would you ask the patient about on history?

    Symptoms to ask for on history:

    • Headache (intracranial haemorrhage)
    • Visual disturbance (increased ICP)
    • Chest pain (ACS, aortic dissection)
    • Back pain (aortic dissection)
    • Dyspnea (CHF, pulmonary edema)
    • Assess for signs of seizure/altered level of consciousness/stroke (hypertensive encephalopathy)
  3. What would you look for on physical exam?

    Physical exam includes:

    • Heart rate, respiratory rate, temperature, SpO2
    • Blood pressure (both arms contemporaneously
    • Neurological exam, LOC
    • Fundoscopy – assess for exudates, retinal hemorrhages, papilledema
    • Cardiac exam – new murmurs, S3, gallop
    • Raised JVP
    • Respiratory exam – crackles
  4. What investigations would you order at this time?

    Investigations at this time include:

    • CBC with peripheral smear (evidence of hemolysis)
    • Lytes, BUN, Creatinine
    • Serum cortisol
    • ECG
    • CXR
    • Urinalysis

The goal of therapy should be rapid reduction of blood pressure (MAP decrease ≤25%) with antihypertensives, by IV if necessary.


  1. Hypertension Canada. Canadian Hypertension Education Program (CHEP) Recommendations. Retrieved from
  2. Marik PE and Rivera R. Hypertensive emergencies: an update. Curr Opin Crit Care. 2011, 17:569-580.
  3. Vaughan CJ and Delanty N. Hypertensive emergencies. The Lancet. 2000, 356:411-417.

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