Diagnose It Answer — April 12, 2026

52-year-old male presents with a severe occipital headache he describes as 'the worst of my life,' onset 2 hours ago. He also reports blurred vision, nausea, and a sensation of pressure behind his eyes. His wife drove him in when he began having difficulty finding words. He has no history of migraines.

Known history of essential hypertension, managed with amlodipine and lisinopril. He ran out of his medications 10 days ago and has not been able to get a refill. Also has a history of chronic kidney disease stage 3 and obstructive sleep apnea. Smokes half a pack per day. Drinks 4–5 alcoholic beverages nightly.

BP 228/138 mmHg (confirmed in both arms — right: 226/136, left: 230/140), HR 94 bpm, RR 20 breaths/min, Temp 36.9°C, SpO2 96% on room air. Patient is alert and oriented but anxious. Fundoscopic exam reveals bilateral papilledema and flame-shaped hemorrhages.

Neurological exam: mild expressive aphasia, otherwise intact. No focal motor weakness. Pupils equal and reactive. Evidence of end-organ damage: altered cognition with aphasia, papilledema on fundoscopy, and acute kidney injury on labs. This presentation is a hypertensive emergency — not urgency — due to confirmed end-organ involvement. IV antihypertensive therapy initiated; goal is to reduce MAP by no more than 25% in the first hour.

Creatinine 2.9 mg/dL (baseline 1.6 mg/dL — acute on chronic kidney injury). Urinalysis: 2+ protein, red cell casts present. BMP: Na 138, K 4.4, CO2 20 (mild metabolic acidosis). CBC: microangiopathic changes on smear — schistocytes noted. Troponin negative. CT head without contrast: no hemorrhage, no mass lesion. MRI brain ordered to evaluate for posterior reversible encephalopathy syndrome (PRES).