CASE PRESENTATION_ Uncontrolled ‘Essential’ Hypertension, Stage II.ppt

CASE PRESENTATION:Uncontrolled ‘Essential’ Hypertension, Stage II Jasjot Garcha MD PGY1, Internal Medicine Allan B. Schwartz, MD Professor of Medicine Division of Nephrology and Hypertension Director of CME, Department of Medicine Drexel University College of Medicine Chief Complaint and HPI: A 55 year old Caucasian male, history of hypertension for 30 years with poor follow up and irregular BP monitoring. Pt. was diagnosed of hypertension at the age of 25 years (160/96). He was treated originally with Serapes (Reserpine + Hydralazine + HCTZ) followed by Propanolol and Triamterene/HCTZ. presents at the nephrology clinic with a nose bleed and accompanied blood pressure of 180/110mm Hg. ROS was within normal limits except for knee pain which is relieved by Ibuprofen. Past medical and surgical history: Paroxysmal atrial tachycardia with hypokalemia( 2.9 mEq/L) in his mid 20s. Family history Father: Died at 75 of Acute M.I. Hypertensive since his 20s with history of paroxysmal atrial tachycardia and paroxysmal atrial flutter. Paternal Grand Father died at 81 of CHF , CAD Social history Physician Runs 4 miles per day Non smoker occasional alcohol consumption Medications: Felodipine 2.5mg QD Metoprolol 50mg BID Triamterene/HCTZ (37.5/25) 1 tablet daily Ibuprofen 600 mg PRN Physical exam: BP:160/90 mm Hg P: 50/min Fundi show diffused arteriolar narrowing and AV nicking. Heart: regular, No m/g Lungs clear Pulses intact Labs and further studies(11/1997): BUN/Cr:30/1.9 TG 323, Total Chol 232, LDL 136, HDL 31 No proteinuria CrCl(Cockcroft Gault) = 45 ml/min ECG: normal Echocardiogram: no LVH Renal scan: 8.6cm right 9.3cm left Renal blood flow scan: no evidence of RAS Serum Cortisol and Aldosterone levels: Normal Further plan: Low salt diet Maintain exercise program Start Quinapril 5mg QD Conitinue Metoprolol 50 mg BID Triamterene/HCTZ 37.5/25 mg QD 24 hr. urine for VMA, catecholamines, metanephrines Consider statin Questions: What is the likely etiology? How do geneti