NMS Q&A Family Medicine

Hypertension 71systolic hypertension, as it is in a majority of African-Americans at any age. Elderly people with hypertension,too, have a tendency for salt-retentive, volume-dependenthypertension. Moreover, hctz and other thiazides, in theelderly, have a vasodilation effect.10. The answer is A. Diabetes is the chief cause of ESRD,accounting for up to 50% of cases, whereas hypertensionis the cause in 27% of cases of ESRD. The pathophysiologicalmechanisms of diabetes type II are under way foryears before the onset of hyperglycemia occurs. This is aresult of insulin resistance and resultant hyperinsulinemia.C-peptide levels are directly related to endogenousinsulin levels. Therefore, this patient, being a prediabetic(elevated C-peptide) with imperfectly treated hypertension,has a double dose of risk factors and must get immediatelyto work towards preservation of renal function(see chapter 17).11. The answer is C. As mentioned in a variety of ways inthis publication, about 35% of whites, Asians, and mostother ethnic groups in the United States (but 65% ofAfrican-Americans) with hypertension have a primarilysalt- and water-retention mechanism and thus respond toboth salt restriction and diuretic therapy.12. The answer is D. Hypertension in the face ofhypokalemia and in the absence of diuretic medication orgastrointestinal or other pathologic loss of potassium isprimary aldosteronism until proven otherwise.13. The answer is C. In primary aldosteronism, the serumbaseline aldosterone level is 20 g/dL. The level doesnot rise after 4 hours of erect posture. A 24-hour urinestudy for aldosterone is also measured and indicateshyperaldosteronism when the excretion is 20 g/24hours. VMA, catecholamines, and metanephrine aremeasured to diagnose pheochromocytoma. Sitting andstanding BP levels are done to diagnose orthostatichypotension.14. The answer is E. Only about 75% to 80% of cases arecured. Not only are 10% of cases bilateral but another10% have metastases at the time of diagnosis. The majorityof patients presenting to the primary care physicianwith paroxysms of anxiety have a phobic reaction or anxietyneurosis by other names; however, many of these individualshave elevated BP levels during attacks of anxietyand are logically evaluated for pheochromocytoma. Sensitivityand specificity for 24-hour urine metanephrinelevels alone are not sufficient to diagnose pheochromocytoma.However, if the specimen is tested also for free catecholaminesand VMA, then they are sufficient, providedthe symptoms occur on the day of the collection or thetumor excretes norepinephrine, which appears on a constantbasis. Familial cases tend to occur in association withmultiple endocrine neoplasia, types II A and II B, and thefamilial cases tend to be bilateral.15. The answer is B. The BP target for therapy andfollow-up of essential hypertension is 130/85. This istrue only for nondiabetic individuals and persons whoare not African-American. The upper limit of normal systolicBP is 139; the pressure definition of stage 4 hypertensionis 210/ 120 mm Hg, according to the JointNational Committee on Detection, Evaluation and Treatmentof High Blood Pressure.16. The answer is D. The patient should be examined foran abdominal bruit, specifically a bruit deep in one flankthat could be generated by renal artery stenosis. Essentialhypertension, be it volume dependent or based more onperipheral vascular resistance, usually has its clinical onsetin a person’s late 30s or 40s. Hypertension significantlyearlier or that which comes on after a person reaches theage of 60 must be evaluated for other causes, of whichrenovascular type is one. When a person is at a youngerage, the cause is most likely due to a congenital fibrousband, which has a 2:1 female-to-male occurrence ratio.After a person reaches the age of 60, the cause is morelikely an atherosclerotic one, which has a 2:1 male-tofemaleoccurrence ratio. None of the other choices hasany specific relevance to the diagnosis of the pathophysiologyof hypertension.ReferencesFamily Medicine Review. Kansas City, Missouri; May 3–9; 2009 .Joint National Committee on Detection . Evaluation and treatmentof high blood pressure (JNC-V). Arch Intern Med1993 ; 153 : 161 .Rudy DR . Hypertension . In: Rudy DR , Kurowski K , eds.Family Medicine: House Officer Series . Baltimore : Williams &Wilkins ; 1997 : 145 – 168 .