HYPERTENSION
HYPERTENSION: Excerpt from Differential Diagnosis in Primary Care
With the emphasis placed on the diagnosis and treatment of hypertension
in the past 20 years, every physician has a good knowledge of the causes of
hypertension. The list nevertheless, may be incomplete. If consideration is
to be given only to the treatable disorders, then one simply needs to
remember the cardiovascular system, adrenal gland, and kidney and apply the
mnemonic VINDICATE to develop a list of the causes (Table
40). It is more instructive, however, to apply physiology in
developing a differential.
Because blood pressure is maintained by an adequate blood volume, an
adequate cardiac output, and appropriate vasomotor tone, it follows that
hypertension may result from an increase in any one or more of these three
factors.
HYPERTENSION
|
| V | I | N | D |
|
| Vascular | Inflammatory | Neoplasm | Degenerative |
|
| | | | |
|
|
Cardiovascular System | | Aortic insufficiency |
Polycythemia vera Intracranial tumor |
Atherosclerosis Medionecrosis |
| |
|
Adrenal Gland |
|
| Pheochromocytomas Cushing disease Primary aldosteronism |
|
Kidney |
Atherosclerotic plague of renal artery (stenosis) |
Pyelonephritis Renal tuberculosis |
Hypernephroma Multiple myeloma |
| |
|
A-V, arteriovenous.
-
Increased blood volume. This results in most cases from an increase
in sodium in the blood from primary aldosteronism (adrenal tumors) or from
secondary aldosteronism (renovascular hypertension from glomerulonephritis
and other primary renal diseases or obstruction of the renal arteries by
atherosclerotic plaques or fibromuscular hyperplasia). Administration of
corticosteroid drugs may cause hypertension by the same mechanism.
Polycythemia vera is often associated with moderate hypertension because of
increased red cell mass.
- Increased cardiac output. This mechanism accounts for the systolic
hypertension in hyperthyroidism, aortic insufficiency, patent ductus
arteriosus, arteriovenous shunts, and Paget disease.
- Increased vasomotor tone. Increased output of epinephrine and
norepinephrine as occurs in pheochromocytoma is one example of this type of
hypertension. Administration of sympathomimetic drugs is another. Essential
hypertension is probably based on this mechanism, but increased total body
sodium leading to an increased blood volume may also be a pathophysiologic
mechanism. Unfortunately, this approach omits dissecting aneurysm and
coarctation of the aorta, two important causes of hypertension.
Approach to the Diagnosis
Take the blood pressure yourself to be sure the hypertension is real;
24-hour blood pressure monitoring is now available. The workup of
hypertension includes a family history, serial electrolytes, urinalysis and
urine culture, and possibly “hypertensive” IVP and 24-hour urine VMA to
rule out treatable causes of hypertension. A complete hypertensive workup is
not usually performed today unless there is no family history of
hypertension, the hypertension does not respond to treatment, there are
other symptoms suggesting a surgical lesion (e.g., paroxysmal headaches), or
there is sudden onset of hypertension in a known normotensive individual.
Other Useful Tests
-
Serum cortisol level (adrenal tumor or hyperplasia)
- Dexamethasone suppression test (adrenal tumor or hyperplasia)
- Plasma renin level (renovascular hypertension)
- 24-hour urine aldosterone (aldosterone-producing tumor)
- Cystoscopy and retrograde pyelography (tumor or malformation of the
urinary tract)
- Renal angiogram (renal artery stenosis)
- CT scan of abdomen (hypernephroma)
HAND AND FINGER PAIN
|
| I | C | A | T | E |
| Intoxication | Congenital | Allergic and | Trauma | Endocrine |
|
| | Autoimmune | | |
|
Sympathomimetics Exogenous corticosteroid Porphyria |
Coarctation of the aorta Patent ductus Essential hypertension |
Polyarteritis nodosa |
A-V fistula Intracranial hemorrhage |
Hyperthyroidism Acromegaly |
|
| | | | Adrenocortical hyperplasia |
| |
|
Toxic nephritis Toxemia of pregnancy |
Polycystic kidney Hydronephrosis Other anomalies |
Glomerulonephritis Vasculitis |
| Kimmelstiel–Wilson syndrome |
|
- Glucagon stimulation test (pheochromocytoma)
- Magnetic resonance angiography (MRA) (renal artery stenosis)
- Ultrasonography (hydronephrosis)
CASE PRESENTATION #50
A 42-year-old white male executive complained of fatigue, frequent
muscle cramps, and frequency of urination at the time of his annual
physical. His blood pressure was 188/115 mm Hg but, otherwise, his physical
examination was unremarkable. His family history is negative for
hypertension.
Pictures
Book Source Details
- Book Title: Differential Diagnosis in Primary Care
- Author(s): R. Douglas Collins MD, FACP
- Year of Publication: 2007
- Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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