Endgames

Case report

A man with high blood pressure

BMJ 2009; 338 doi: 10.1136/bmj.b1550 (Published 6 May 2009)
Cite this as: BMJ 2009;338:b1550

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  1. Brian McKinstry, reader in primary care research 1,
  2. Paul Padfield, professor of hypertension2
  1. 1Centre for Population Health Sciences, General Practice Section, University of Edinburgh, Edinburgh EH8 9DR
  2. 2 Department of Medical Sciences, Western General Hospital, Edinburgh EH42XU
  1. Correspondence to: B McKinstry brian.mckinstry{at}ed.ac.uk

    A 29 year old white man presented to general practice after a routine check at work, which was carried out because he felt lightheaded. His work found a blood pressure of 178/104 mm Hg and a pulse rate of 100 beats/min. His cousin, who was a nurse, rechecked his blood pressure and found it to be 138/92 mm Hg. He was not a regular attendee at the surgery and was taking no drugs. He had occasionally felt lightheaded during the past year, but he had never fainted. He had a family history of high blood pressure. He was slim (body mass index of 20), and in the surgery he had a blood pressure of 172/94 mm Hg and a pulse rate of 98 beats/min. Optic fundi, peripheral pulses, heart sounds, and chest examination were all normal. He had no abdominal bruits.

    Questions

    • 1 What is the most likely diagnosis?

    • 2 What other conditions might you suspect?

    • 3 How would you assess him further?

    • 4 How would you manage and follow up this patient?

    Answers

    Short answers

    • 1 Primary “essential” hypertension or “white coat hypertension” (high in surgery but normal at home).

    • 2 Secondary hypertension caused by drug misuse, phaeochromocytoma, primary aldosteronism, renal failure, renal artery stenosis, or coarctation of the aorta.

    • 3 Take a history to exclude drug and alcohol misuse as causes. Ask him about symptoms of palpitations or sweating. Measure urea, electrolytes, lipids, and random blood glucose. Carry out a full blood count, liver function tests, urinalysis, ambulatory blood pressure monitoring, and resting …

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