A 35-year-old woman with hypertension

Problem 38 A 35-year-old woman with hypertension



Anne Tonkin



A 35-year-old woman presents to the emergency department complaining of 5 days of progressive generalized headache and nausea. Her blood pressure is measured and is recorded at 250/140 mmHg. The patient states that she has a family history of hypertension and was noted to be hypertensive for the first time 2 years ago. She had no investigations, but was treated with verapamil 80 mg tds. The patient stopped taking this after a few months because it made her constipated.


Q.1


What condition(s) may be responsible for this patient’s presentation? What further history is required from her?


The patient does not have any relevant previous illnesses and had a tubal ligation 6 years ago. She complains of sweating, palpitations and anxiety. She takes no drugs, but smokes 10 cigarettes a day and consumes 100 g alcohol a week.



Q.2


What would you look for on examination?


On examination the patient is anxious and sweaty, but otherwise appears fit. Her pulse rate is 120 bpm and regular and her blood pressure 250/140 mmHg. Significant abnormalities include a forceful but undisplaced apical cardiac impulse without evidence of left ventricular failure, and a bruit in the left side of her abdomen. Urinalysis reveals 1+ (0.3 g/L) albumin only. Her retina is shown in Figure 38.1.


image

Figure 38.1



Q.3


What does this retinal photograph show?


The changes seen on fundoscopy are consistent with the clinical picture of severe hypertension.


You insert a radial arterial line for accurate monitoring of blood pressure and admit her to the high dependency ward. Her blood pressure improves with your chosen therapy, and you now have time to think about the possible cause of her hypertensive crisis.


The patient’s complete blood picture, ESR, biochemistry, urine microscopy and culture and chest X-ray were normal. The ECG showed a sinus tachycardia and left axis deviation, but was otherwise normal. Urinary catecholamines were within normal limits.



Q.5


What are the possible causes of this woman’s hypertension and what investigations would you like to organize?



Q.4


What type of treatment should immediately be instituted?


A renal ultrasound scan is normal. A radionuclide scan of the kidneys is performed, showing delayed perfusion and delayed function of the left kidney and then late hyperconcentration of the isotope in the left kidney. The right kidney contributes 65% of total renal function and the left kidney contributes 35%.


The patient went on to have the investigations shown in Figure 38.2 and Figure 38.3.


image

Figure 38.2


image

Figure 38.3



Q.6


What is the investigation and what does it show? How can this condition be treated?


These results strongly suggest left renal artery stenosis, but the diagnosis should be confirmed by either MRAngiography or intra-arterial renal angiography.


The patient had the most marked stenotic segment dilated via percutaneous transluminal balloon angioplasty, with a dramatic improvement in her blood pressure.


An important lesson in this case is that the patient was inadequately assessed on her first presentation with hypertension 2 years earlier. At that time the minimum investigation should have included urinalysis, serum biochemical analysis, ECG and possibly echocardiography (to assess for left ventricular hypertrophy), chest X-ray and lipid profile. In addition, there should have been careful follow-up and counselling to stop smoking.


In view of her young age, a specific underlying cause of her hypertension should have been considered. Further, if the abdominal bruit had been listened for (and been present and found) at her initial presentation, her fibromuscular dysplasia may have been diagnosed and the subsequent emergency avoided.


Patient education is vital to prevent loss to follow-up. If unacceptable side-effects occur, a switch to an alternative medication will promote compliance. Otherwise, their hypertension may go untreated for long periods.



Answers


A.1 She may have poorly controlled essential hypertension or hypertension secondary to underlying kidney disease, and an intercurrent problem such as a viral illness which has produced the headache and nausea. However, she has marked hypertension for a young person and may be in a hypertensive crisis. In this situation encephalopathy can occur which would be suggested by the headache and nausea. Her past medical history will be important as she may give a history of known poorly controlled hypertension or renal disease. You must inquire as to whether she may be pregnant (pre-eclampsia), although such severe hypertension would be very uncommon in early pregnancy.


You should ask her about the severity of her previously diagnosed hypertension, and whether she knows of her recent blood pressure readings – if it has been progressively increasing over several months the immediate risk is lower than if this has been a sudden rise over a few days or weeks.


Ask her about other symptoms associated with hypertensive encephalopathy such as irritability, visual disturbances, confusion, altered consciousness and seizures.


Ask about symptoms that might suggest an underlying disorder to account for her hypertension, such as:


• Renal disease: thirst, polyuria, nocturia, dysuria, haematuria, colic, lethargy and general malaise of uraemia.

• Phaeochromocytoma: sweating, palpitations, anxiety and tremor, particularly occurring in paroxysms.

• Cushing’s syndrome: truncal weight gain, thinning of skin, easy bruising, weakness of proximal limb muscles, striae, hirsutism.

You will also need to ask about symptoms suggestive of hypertensive damage to the retina (visual deterioration) or the cardiovascular system, including acute myocardial ischaemia or cardiac failure (angina, dyspnoea, orthopnoea, ankle swelling), and aortic dissection (back pain).


A drug history is vital, including past use of analgesics (particularly NSAIDs: analgesic nephropathy), current use of drugs associated with hypertension, e.g. oral contraceptive pill, sympathomimetics (e.g. nasal decongestants), steroids, some antidepressants (including venlafaxine) and combinations of antidepressants associated with a risk of serotonergic syndrome (e.g. SSRIs and monoamine oxidase inhibitors). The patient’s use of tobacco, alcohol and illicit drugs, particularly cocaine and amphetamine derivatives, should also be explored.


A.2 On examination you will need to look for evidence of hypertensive damage to:


• The CNS (level of consciousness, visual fields, focal neurological deficits).

• The retina (hypertensive retinopathy, especially haemorrhages, new exudates or optic disc swelling).

• The heart (left ventricular hypertrophy, left ventricular failure).

• The aorta (unequal pulses in aortic dissection).

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Apr 2, 2017 | Posted by in GENERAL SURGERY | Comments Off on A 35-year-old woman with hypertension

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