Intended for healthcare professionals

Endgames Case report

A man with high blood pressure

BMJ 2009; 338 doi: (Published 06 May 2009) Cite this as: BMJ 2009;338:b1550
  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}

    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.


    • 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?


    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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