A 42-year-old woman with hypertension

Problem 6 A 42-year-old woman with hypertension



Lucia Gagliardi




You are a medical resident in a major teaching hospital. A 42-year-old woman is referred to your outpatient clinic for assessment and management of hypertension. The referral letter states that she was diagnosed with hypertension 8 years ago. She remains hypertensive (blood pressure 150/90 mmHg to 180/100 mmHg when checked by her general practitioner) despite treatment with three agents (irbesartan, indapamide and amlodipine). She was diagnosed with ‘anxiety’ several years ago, for which she has been taking diazepam. She has had no other major illnesses. There is no family history of hypertension.



Q.1


What are the possible aetiologies of hypertension in this patient?



Q.2


What questions will you ask her and what will you look for on physical examination?


She was diagnosed with hypertension 8 years ago and this has never been well controlled. She has been on the current treatment regimen for the last 3 years and is compliant. She self-monitors her blood pressure at home and obtains readings between 140/90 mmHg and 200/100 mmHg. She has no explanation for this variation.


She was diagnosed with ‘anxiety’ around the same time the diagnosis of hypertension was made. This diagnosis was based on intermittent episodes of palpitations, shortness of breath, sweating, associated with a feeling of ‘impending doom’. She has had no headaches. She has been diagnosed and managed by her local general practitioner.


In the last 2 years she has experienced central weight gain (10 kg), which has occurred despite diet and exercise. She has never had depression and has not had any problems with concentration. She has not experienced increased facial hair or acne. Her muscle strength has always been good. She slipped and fell 2 months ago and sustained a fractured radius. Her periods are regular. She has two children – aged 15 and 10. Both pregnancies were uncomplicated. She is not on the oral contraceptive and does not take any other medications. She drinks 1–2 standard drinks per week and is a non-smoker. Her mother had diabetes; her father is alive and well. There is no other family history of hypertension or endocrine or renal disease.


On examination she appears slightly anxious, and is tremulous. She is overweight, but there are no clinical features of Cushing’s. Her blood pressure is 170/90 mmHg lying and 160/85 mmHg standing. Her pulse is 110 bpm and regular. She has a forceful, non-displaced apex beat; examination of the cardiovascular system is otherwise unremarkable. There are no abdominal masses or striae visible or bruits audible. She is able to stand from a squat without difficulty. On fundoscopy there is silver wiring.



Q.3


What investigations will you perform?


The following results are available.


Investigation 6.1 Summary of results






























Fasting glucose (3.8–5.5 mmol/L) 10
Urea (2.7–8.0 mmol/L) 7.3
Creatinine (50–120 µmol/L) 68
eGFR (mL/min/1.73 m2) >60
Ionized calcium (1.1–1.25 mmol/L) 1.31
Total calcium (2.10–2.55 mmol/L) 2.75
Phosphate (0.65–1.45 mmol/L) 1.27
Plasma metanephrine 18 100 pmol/L (<500 pmol/L)
Plasma normetanephrine 9260 pmol/L (<900 pmol/L)


Q.4


Please discuss the results. What is the diagnosis? What will be your next step(s)?


Some imaging studies are arranged and a CT scan of the abdomen performed. A representative slice is shown (Figure 6.1).


image

Figure 6.1



Q.5


What does the scan show?


She is tolerating phenoxybenzamine well, but has been tachycardic (heart rate 110–120 bpm for the last 2 days).



Q.6


What should be done next?


She undergoes a laparoscopic adrenalectomy and the large adrenal tumour is removed intact. As soon as the adrenal vein is ligated the blood pressure falls and the anaesthetist is able to reduce the alpha blockade. The opened surgical specimen is shown (Figure 6.2).


image

Figure 6.2


All medications are stopped immediately postoperatively.



Q.7


What postoperative complications should she be observed for?


Over the next week her blood pressure without medication varies between 100/70 and 125/80 mmHg. The histopathology is consistent with a phaeochromocytoma.



Q.8


What follow-up is necessary for this patient?



Answers


A.1 In this patient, secondary hypertension should be suspected because she has refractory/resistant hypertension – remaining hypertensive despite three antihypertensive drugs – and has no family history of hypertension. The possible causes of secondary hypertension in this patient include:


• Endocrine (phaeochromocytoma, Cushing’s syndrome, Conn’s syndrome).

• Renal (renovascular disease, primary renal disease).

• Other (coarctation of the aorta, oral contraceptive pill).

She must be investigated for a secondary cause of hypertension.


A.2 The following components of the history should be clarified:


• Hypertension – previous treatment; compliance with medications.

• Diagnosis of ‘anxiety’ – how diagnosis made – including whether psychiatric or psychological evaluation was performed; description of symptoms (chest pain, shortness of breath, increased respiratory rate, sweating, symptoms persistent or episodic, precipitating factors).

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Apr 2, 2017 | Posted by in GENERAL SURGERY | Comments Off on A 42-year-old woman with hypertension

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