Browse categories and answer follow-up questions to refine your symptom profile.
History
Presentation pattern
BP context
Incidental reading
Symptomatic elevation
Persistent elevation despite rest
Baseline BP history
Prior diagnosis essential hypertension (I10)
Prior home BP values
Recent changes
Medication missed doses
New medication started
Recent dose change
End organ symptom screen
Chest pain
Dyspnea
Neuro deficit
Severe headache
Visual change
Oliguria
Pregnancy related symptoms
OPQRST
Applicable symptom OPQRST
Onset
Sudden
Gradual
Provocation and palliation
Exertion related
Relief with rest
Quality
Pressure
Tearing
Region and radiation
Chest to back
Head and neck
Severity
Mild
Severe
Timing
Constant
Intermittent
Associated symptoms
Neuro
Confusion
Seizure
Syncope
Cardiac
Palpitations
Diaphoresis
Renal
Hematuria
Flank pain
Alarm Features
Immediate escalation triggers
Hypertensive emergency features
Acute neuro deficit
Suspected stroke
Suspected intracranial hemorrhage
Seizure
Altered mental status
Acute coronary syndrome concern
Acute pulmonary edema
Aortic syndrome concern
Acute kidney injury concern
Eclampsia or severe preeclampsia concern
High risk vitals patterns
Persistent severe BP despite repeat measurement
Hypoxia
Shock physiology
Danger findings
Exam red flags
New focal neurologic deficit
Papilledema
Pulmonary edema signs
Pain red flags
Sudden severe chest pain
Sudden severe back pain
Medications
Current medication exposure
Antihypertensives
ACE inhibitor
ARB
Thiazide
Dihydropyridine calcium channel blocker
Beta blocker
OTC and supplements
NSAID
Decongestant sympathomimetic
Drugs that raise BP
Stimulant prescribed
Cocaine
Amphetamine
Steroid
Calcineurin inhibitor
High risk interactions and contraindications
Pregnancy relevant contraindications
ACE inhibitor fetal risk
ARB fetal risk
Acute heart failure considerations
Non dihydropyridine calcium channel blocker avoidance in HFrEF
Excess fluid bolus avoidance
Substance related considerations
Sympathomimetic intoxication
Local protocol dependent beta blockade strategy
Diet
Intake and exposures
Sodium pattern
High sodium meals
Processed foods
Caffeine and energy drinks
High caffeine intake
Recent increase
Alcohol exposure
Recent binge
Withdrawal risk
Hydration context
Volume depletion cues
Poor intake
Vomiting
Volume overload cues
Recent weight gain
Orthopnea
Review of Systems
Cardiopulmonary
Symptoms
Chest pain
Dyspnea
Orthopnea
PND
Edema
Neurologic
Symptoms
Headache
Weakness
Speech difficulty
Vision change
Confusion
Renal and endocrine
Symptoms
Decreased urine output
Hematuria
Flank pain
Episodic sweating and headache
Episodic palpitations
Collateral History and Family History
Collateral
Source and reliability
Family report
EMS report
Home BP log availability
Device type
Measurement technique
Family history
Premature cardiovascular disease
MI before age 55 male first degree relative
MI before age 65 female first degree relative
Heritable conditions
Polycystic kidney disease (Q61.3)
Pheochromocytoma syndromes
Risk Factors
Cardiovascular risk
Comorbidities
Diabetes mellitus type 2 (E11.9)
Chronic kidney disease (N18.9)
Dyslipidemia (E78.5)
Obstructive sleep apnea (G47.33)
Lifestyle factors
Tobacco use
High sodium diet
Secondary hypertension risk
Renal causes
Renal artery stenosis
Chronic kidney disease
Endocrine causes
Hyperthyroidism (E05.90)
Primary hyperaldosteronism
Pheochromocytoma
Pregnancy related
Preeclampsia risk factors
Postpartum hypertension window
Differential Diagnosis
Life threatening
Hypertensive emergency (I16.1)
Acute target organ injury present
Requires IV BP control
Aortic dissection (I71.00)
Sudden tearing chest or back pain
Pulse deficit
Intracerebral hemorrhage (I61.9)
Sudden severe headache
Focal deficit
Acute ischemic stroke (I63.9)
Focal neurologic deficit
Thrombolysis eligibility implications
Acute coronary syndrome (I20.0)
Ischemic chest pain
ECG ischemia
Acute cardiogenic pulmonary edema (I50.1)
Hypoxia
Crackles
Eclampsia and severe preeclampsia (O14.1)
Pregnancy
Seizure
RUQ pain
Common
Essential hypertension (I10)
Longstanding
No acute target organ injury
Pain driven BP elevation
Trauma
Renal colic
Anxiety related BP elevation
Panic symptoms
Normalization after rest
Less common
Medication induced hypertension
NSAID exposure
Stimulant exposure
Secondary hypertension
Renal artery stenosis
Primary aldosteronism
Thyrotoxicosis
Autonomic dysfunction
Dysautonomia
Baroreflex failure
Past Medical History
Baseline conditions
Hypertension related complications
Prior stroke or TIA (I63.9)
Prior MI (I21.9)
Kidney disease
CKD stage
Baseline creatinine trend
Heart failure
HFrEF history (I50.20)
Prior pulmonary edema episodes
Procedures and devices
Vascular history
Prior aortic aneurysm
Prior vascular surgery
Pregnancy history
Prior preeclampsia
Postpartum complications
Physical Exam
Measurement and general
BP confirmation
Correct cuff size
Repeat after 5 minutes rest
Both arms if concern for dissection
General appearance
Toxic appearance
Respiratory distress
Cardiopulmonary
Perfusion and volume status
JVP elevation
Peripheral edema
Lung exam
Crackles
Wheeze
Cardiac exam
New murmur
S3 gallop
Neurologic and ocular
Neuro exam
Mental status
Cranial nerves
Motor strength
Speech and language
Fundoscopic cues
Papilledema
Retinal hemorrhage
Vascular
Pulse and limb assessment
Pulse symmetry
Limb ischemia signs
Dissection clues
Pulse deficit
Focal neuro deficit with pain
Lab Studies
Core ED labs
Metabolic and renal
Electrolytes
Creatinine
BUN
Urine testing
Urinalysis protein
Urinalysis blood
Hematology
CBC
Platelets
Target organ evaluation
Cardiac injury
Troponin with chest pain
BNP with pulmonary edema concern
Pregnancy testing
Beta hCG for reproductive age
Urine protein assessment in pregnancy
Interpretation pearls and pitfalls
Kidney injury context
Baseline creatinine comparison
Prerenal features
Troponin timing limitation
Early negative does not exclude ACS
Serial testing pathway local protocol dependent
Imaging
Scoring Systems
Aortic Dissection Detection Risk Score
High risk conditions
High risk pain features
High risk exam features
ICH score
When intracerebral hemorrhage confirmed
Prognostication support
MRI
Brain MRI
Suspected posterior circulation stroke with nondiagnostic CT
Contraindications
Renal artery MRI
Secondary hypertension workup outpatient pathway
Local protocol dependent availability
CT
Noncontrast CT head
Focal neurologic deficit
Altered mental status
CT angiography chest abdomen pelvis
Aortic syndrome concern
Contrast nephropathy risk context
Ultrasound
POCUS lung
B lines for pulmonary edema
Pleural effusion
POCUS cardiac
LV function gross estimate
Pericardial effusion
Renal ultrasound
Hydronephrosis in flank pain
Chronic kidney disease morphology
Special Tests
Bedside diagnostics
Fundoscopy adjunct
Papilledema
Retinal hemorrhage
Point of care ultrasound integration
Volume status support
Pulmonary edema support
Secondary cause screening cues
Orthostatic vitals
Volume depletion pattern
Autonomic dysfunction pattern
TSH testing trigger
Weight loss and tremor
Heat intolerance
ECG
Indications and patterns
Indications
Chest pain
Dyspnea
Syncope
Ischemia patterns
ST elevation
ST depression
T wave inversion
Strain and hypertrophy
LVH criteria
Lateral strain pattern
High risk findings
Arrhythmia
AF with RVR
Ventricular tachycardia
Conduction disease
New LBBB
High grade AV block
Assessment
Phenotype classification
Severe asymptomatic hypertension
No acute target organ injury
Often chronic uncontrolled
Hypertensive emergency (I16.1)
Acute target organ injury
Time sensitive BP reduction
Hypertensive encephalopathy (I67.4)
Headache
Confusion
Improvement with controlled BP lowering
End organ injury mapping
Neuro
Stroke suspected
Intracranial hemorrhage suspected
Cardiac
ACS suspected
Acute heart failure
Vascular
Aortic syndrome concern
Acute limb ischemia concern
Renal
AKI concern
Hematuria and proteinuria concern
Pregnancy
Severe features present
Magnesium indicated pathway
Plan
First 5 minutes
Immediate stabilization
Monitor
IV access
Repeat BP with correct cuff
Triggered rapid pathways
ECG within 10 minutes for chest pain or dyspnea
CT head pathway for neuro deficit
Immediate consult triggers
Stroke team for suspected acute stroke
Cardiology for ACS and pulmonary edema
Vascular surgery for aortic syndrome concern
Obstetrics for pregnancy severe BP
BP targets and rate of reduction
General hypertensive emergency target
MAP reduction 20 percent to 25 percent in first hour
Avoid rapid normalization
Aortic dissection target
HR target less than 60
SBP target less than 120
Acute ischemic stroke not thrombolysis candidate
Permissive hypertension
Treat if BP greater than 220 over 120
Thrombolysis eligible stroke
BP target less than 185 over 110 before thrombolysis
BP target less than 180 over 105 after thrombolysis
Intracerebral hemorrhage
SBP target 140 to 160 local protocol dependent
Avoid hypotension
Pregnancy severe range BP
Treat if BP 160 over 110 or higher
Seizure prophylaxis pathway if indicated
IV antihypertensives dosing examples
Nicardipine infusion
Start 5 mg per hour
Titrate 2.5 mg per hour every 5 to 15 minutes
Maximum 15 mg per hour
Clevidipine infusion
Start 1 mg per hour to 2 mg per hour
Double every 90 seconds to 3 minutes until near goal
Maximum 21 mg per hour local protocol dependent
Labetalol IV bolus
20 mg IV over 2 minutes
Repeat 20 mg to 80 mg every 10 minutes as needed
Maximum 300 mg
Labetalol infusion
0.5 mg per minute to 2 mg per minute
Titration local protocol dependent
Esmolol infusion
Load 500 mcg per kg over 1 minute
Start 50 mcg per kg per minute
Titrate by 50 mcg per kg per minute every 5 minutes
Nitroglycerin infusion
Start 5 mcg per minute
Increase by 5 mcg per minute every 3 to 5 minutes
Typical range 5 mcg per minute to 200 mcg per minute
Nitroprusside infusion
Start 0.3 mcg per kg per minute
Titrate to effect
Cyanide and thiocyanate toxicity risk
Special situation medication choices
Pulmonary edema phenotype
Nitroglycerin preferred
Nicardipine alternative
Aortic dissection phenotype
Beta blockade first
Add vasodilator after HR control
Pregnancy severe range BP
Labetalol IV
Hydralazine IV
Nifedipine PO immediate release local protocol dependent
Sympathomimetic intoxication
Benzodiazepines for agitation
Vasodilator choice local protocol dependent
Avoid and do not do
Avoid rapid BP lowering in asymptomatic severe hypertension
Ischemic stroke risk
Myocardial ischemia risk
Avoid ACE inhibitor and ARB in pregnancy
Fetal renal injury risk
Oligohydramnios risk
Avoid nitroprusside in pregnancy when alternatives available
Fetal toxicity concern
Maternal toxicity concern
Reassessment loop
Monitoring cadence
Recheck BP every 5 to 15 minutes during titration
Continuous pulse oximetry for respiratory symptoms
Response assessment
Symptom improvement
Neuro status change
Urine output trend
Disposition
ICU criteria
Hypertensive emergency
IV titratable infusion required
Active target organ injury
Aortic syndrome concern
Continuous monitoring
Surgical readiness
Neuro emergency
Intracranial hemorrhage
Thrombolysis or thrombectomy pathway
Inpatient and observation criteria
Inpatient admission
AKI with rising creatinine
ACS workup required
Persistent pulmonary edema
Observation pathway
Need for serial troponins
Need for short interval BP trend
Discharge criteria
Severe asymptomatic hypertension
No target organ injury on evaluation
Reliable follow up
Follow up timing
Primary care within 3 to 7 days
Earlier follow up if new medication started
Discharge Instructions
Copy discharge instructions
Summary
High blood pressure today without signs of organ damage on testing
Blood pressure can be high due to missed medications, stress, pain, or chronic hypertension
Medications
Take your prescribed blood pressure medicines as directed
Do not stop medicines suddenly unless told by your clinician
Home monitoring
Check blood pressure at home
Record readings
Follow up
Book a follow up appointment within 3 to 7 days
Bring your home readings to the appointment
Return to ED now if
Chest pain
Trouble breathing
Severe headache
Weakness
Trouble speaking
Vision changes
Fainting
Seizure
Pregnancy warning
If pregnant or recently postpartum and BP is high, urgent reassessment is needed
References
Guidelines and core sources
Reference set
AHA Scientific Statement on management of elevated blood pressure in acute care settings 2024
ACC AHA Guideline for the Prevention Detection Evaluation and Management of High Blood Pressure in Adults 2017
ESC ESH Guidelines for the management of arterial hypertension 2018
ACOG guidance on hypertension in pregnancy and severe range blood pressure management 2020
AHA ASA Guidelines for early management of acute ischemic stroke 2019 update
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.