100 Cases in Clinical Medicine

CASE 37: HIGH BLOOD PRESSURE

History

A 36-year-old woman is referred by her general practitioner (GP) to a hypertension clinic.
She was noted to be hypertensive when she joined the practice 2 years previously. Her
blood pressure has been difficult to control and she is currently taking four agents (ben-
drofluazide, atenolol, amlodipine and doxazosin). She had normal blood pressure and no
pre-eclampsia during her only pregnancy 9 years previously. There is no family history
of premature hypertension. She smokes 20 cigarettes a day and drinks less than 10 units a
week. She is not on the oral contraceptive pill. She works part time as a teaching assistant.

Examination

She is not overweight and looks well. Her pulse rate is 68/minute and blood pressure
180/102 mmHg. There is no radiofemoral delay. There are no café-au-lait spots or neuro-
fibromas. Examination of the cardiovascular, respiratory and abdominal systems is nor-
mal. The fundi show no significant changes of hypertension.

Normal

Haemoglobin 13.3 g/dL 11.7–15.7 g/dL

White cell count 6.2% 109 /L 3.5–11.0% 109 /L

Platelets 266 % 109 /L 150–440% 109 /L

Sodium 139 mmol/L 135–145 mmol/L

Potassium 4.4 mmol/L 3.5–5.0 mmol/L

Urea 10.7 mmol/L 2.5–6.7 mmol/L

Creatinine 136 &mol/L 70–120&mol/L

Albumin 42 g/L 35–50 g/L

Urinalysis: no protein; no blood

Renal ultrasound: normal size kidneys

Results of a renal angiogram are shown in Fig. 37.1.

INVESTIGATIONS

Figure 37.1Renal angiogram.

Questions

• What is the diagnosis?


• How would you further manage this patient?