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Old 11-06-2012
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Arrow Gyrus Daily Questions; Internal Medicine #71

A 28-year-old man comes to the physician because of a 6-month history of persistent headaches that are vague and dull He has had no fever, neck stiffness, change in vision, nausea, or vomiting. His medical history is unremarkable. Current medications include ibuprofen as needed for the headaches He does not smoke or drink alcohol His blood pressure is 155/90 mm Hg and pulse 70imin One year ago his blood pressure was 107/64 mm Hg Cardiac examination shows normal Si and S2. no murmurs are heard No abdominal bruits are heard There is no peripheral edema One week later, repeat blood pressure is 150/70 mm Hg and pulse 75/min Laboratory studies show:

Na -147 mEq/L
K - 3.0 mEq/L
Cl - 107 mEq/l
HCO - 30 mEq/L
Urea nitrogen (BUN) - 13 mq/L
Creatinine 0.8 mq/L

Which of the following is the most appropriate next step in diagnosis'?

A. 24-hr urine for catecholamine and metanephrine
B. Aldosterone
C. Insulin-like growth factor-1 levels
D. Random serum cortisol
E. Renin
F. Renin and aldosterone
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Old 11-06-2012
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This is an obvious case of SECONDARY hypertension... due to the patient age mostly..

The low potassium and High HCO3- are screaming Hyperaldosteronism outloud... the only thing we can do is differentiate this Hyperaldosteronism as either primary or secondary.. and for that we need both RENIN AND ALDOSTERONE levels or ratio.. whatever you want.. and based on that decide what to do.. which most of the time will be eplerenone because a male with boobs isnt to nice
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F. Renin and aldosterone

His hypertension is primarily systolic.
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Last edited by Novobiocin; 11-06-2012 at 08:21 PM.
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Old 11-06-2012
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Answer is correct.. F.

The patient described has new onset hypertension, confirmed on repeat measurement In a 28-year-old man who does not have a history of hypertension. a secondary cause must be pursued He denies alcohol consumption. and no renal bruits were auscultated. although this finding is insensitive He does have hypokalemia, however. suggestive of an excess mineralocorticoid state Determining the source of the excess mineralocorticoids is based on the levels of renin and aldosterone

If both aldosterone and renin levels are low, then the possibilities include Cushing syndrome or licorice ingestion Aldosterone and renin levels are low because of the cross-reactivity of cortisol and licorice, respectively, on mineralocorticoid receptors

If the aldosterone level is elevated and the renin level is suppressed. then primary aldosteronism is the most likely etiology.

If renin levels are high and aldosterone levels are high. then a hypoperfusion state is the most likely etiology

Hence, both renin and aldosterone levels are required to obtain the plasma aldosteroneiplasma renin ratio, therefore. aldosterone only (choice B) and renin only (choice E) are incorrect

Because this ratio is fairly constant over many physiologic conditions, a random level suffices as a screening test (normal <10 ng/mL/h) When the ratio >20-25 ng/mLJh. sensitivity reaches 95% and specificity 75% for primary hyperaldosteronism Primary hyperaldosteronism will also cause hypokalemia and metabolic alkalosis. which this patient has Any patient with hypertension and unexplained hypokalemia (not on diuretics) should be worked up for primary hypealdosteronism.


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