Hypertensive urgency is characterized by a marked elevation in blood pressure without acute target organ damage. In rural primary care settings, management can be challenging due to limited drug availability, diagnostic tools, and specialist access. A 48-year-old male presented to a rural clinic with palpitations but no chest pain, dyspnea, or neurological symptoms. His blood pressure was 230/120 mmHg with a heart rate of 104 bpm. Physical examination was unremarkable, and ECG showed ST-segment elevation in leads V1-V4 with deep Q waves and left ventricular hypertrophy. Two doses of sublingual nifedipine failed to reduce blood pressure. After remote consultation with a cardiologist, bisoprolol and amlodipine were administered, lowering the blood pressure to 150/90 mmHg after 24 hours. The patient remained stable. Hypertensive urgency should be managed with gradual blood pressure reduction using appropriate oral agents. Sublingual nifedipine is not preferred due to the risk of rapid hypotension and ischemia. Persistent ST elevation with deep Q waves may indicate an old myocardial infarction or left ventricular aneurysm, and echocardiography is valuable for assessing left ventricular function. In settings lacking cardiac enzyme testing and imaging, empirical treatment for acute coronary syndrome may be considered. This case emphasizes the importance of adaptive decision-making in resource-limited settings. Collaboration with specialists, rational use of available medications, and adherence to guideline-based approaches can improve outcomes in managing hypertensive urgency.