Question of the Week # 381

381)  A 32 year old Caucasian man is evaluated in your office for hypertension. He reports that he was first noted to have high blood pressure 6-months ago at which time the reading was 146/92 . At that time, he was asked to follow-up in the office however, he disregarded the advise. Recently, during a pre-employment check-up and again at a community health fair, he was noted to have high blood pressure above 150/90 . He denies any dizziness, chest pain, palpitations or shortness of breath. He does not smoke or does not drink alcohol. His mother was diagnosed with hypertension at 60 years of age and father has had hypertension since the age of 50. He  On examination, his blood pressure is 154/98. Body Mass Index is 24kg/m2. Cardiac examination shows regular heart sound with no S3 gallop or S4. There are no audible murmurs. Abdominal examination is benign and there are no audible bruits. Femoral and radial pulses are normal with out any delay. Ophthalmological examination is normal An electrocardiogram is normal with no evidence of left ventricular hypertrophy. Serum creatinine is 1.0mg% and Urinalysis is normal. Which of the following  is the most appropriate next step in evaluating his Hypertension?

A) Renal Artery Magnetic Resonance Angiography

B) 24 Hour Urinary Metanephrines

C) Plasma Renin Activity- Aldosterone Ratio

D) Ambulatory Blood Pressure monitoring

E) No additional diagnostic work-up

12 Responses

  1. A)

  2. D) Ambulatory Blood Pressure monitoring – to rule out white coat hypertension?

    • His BP is high for 3 measurements. I think it already rules out white coat hypertension???

      • If he does have White coat hypertension then no matter how many times his BP is measured in the office it is going to remain elevated unless addressed.

        The reason i picked D was because he has absolutely no risk factors for essential hypertension or secondary hypertension.His parents hypertension seems to be age related due to vascular changes.

        Would like to know if i’m right.

      • A white coat hypertension should have a clear history that the patient’s blood pressure has always been high in the office but he has had normal readings at home or elsewhere, in settings such as local pharmacy or community health fair.
        Such history is absent here. White coat HTN is often seen only when BP is checked in the office by a doctor but it is often normal when checked by a nurse or an assistant ( Note the question also says the BP at community health fair has been high as well).
        Remember LVH can be absent in recent onset HTN or white coat HTN. Absence of LVH does not rule out essential HTN but it’s presence will always rule out white coat HTN ( apply this concept to question 383)

      • Thanks for the clarification always enjoy your questions…., i did’nt notice the community health fair part .Read this somewhere for someone who would like to know what community health fair is like.

        “There is nothing like a good community health fair. Away from the formal, detached sterility of the office this is an opportunity to meet patients on their turf. No longer adorned with white coat, power outfit and accompanying entourage, physician meets patient as just another member of the community, an equal almost. With a backdrop of blaring music, sweltering heat and flavorful eats people young and old gather, eager to commune in the name of health. Meeting in this context fosters rapprochement between patient and doctor. The once hierarchical encounter is no more. In this habitat, doctor and patient are in fellowship” 🙂

      • Very nice! Thank you!

  3. E) No additional diagnostic work-up
    Patients with mild to moderate hypertension should start with life style modification. If pt have DBP > 90 mmHg despite 3-6 mth trial of nonpharmacological therapy should be started on antihypertensive.

    Pts < 30 require investigation for Secondary hypertension. Since he is 32 and no specific S/S that suggest secondary hypertension.

  4. E, >30 yo with no spesific symp and syg, no more dx w/u.

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