A Case of Hypertension Dr. Susan Poe, case presentation Dr. Paul Kellerman, topic discussion October 10, 2007

No financial incentives

Case JM is a 73 yo white widowed woman presenting with long standing hypertension. She was diagnosed with hypertension at age 35 and has been on a variety of medications since that time. Previous meds include: HCTZ, atenolol, dyazide, lisinopril, losartan, and verapamil. Most recently verapamil and HCTZ/triameterene. BP controlled has fluctuated but overall has been suboptimal.

Case continued.. Pt c/o chronic fatigue and nonspecific aches and pains. No cardiovascular c/o. Recently completed 1 year course of ribavarin and interferon for Hep C Developed hypothyroidism during above treatment, now controlled.

PMH 1.Hepatitis C with stage III fibrosis diagnosed 1995, treated with interferon 1995 and combination ribavirin and interferon until 4/05-3/06. 2.Hypothyroidism- onset during above course 3.Atrial fibrillation 1992 and 7/06 during acute illness 4.Recurrent diverticulitis 5.Osteopenia 6.GI bleed presumed secondary to diverticulosis 7.Drug induced lupus 8.Elevated ANA 9.Asthma 10.TAH/BSO

Medications Verapamil 360 mg qd Maxide 37.5/50 mg qd Synthroid 25 mcg qd MVI

Social History Widowed, retired nurse Lives alone 3 grown children, all with htn Minimal alcohol Nonsmoker

Physical Exam BP 160/80, HR 68, wt 125 Pleasant, no distress HEENT: no thyromegaly or lymph nodes Chest clear to A and P CV RRR no murmur, gallop or rub ABD soft nontender no organomegaly or masses. No abdominal bruits EXT no edema. Normal pulses Neuro grossly intact

Routine labs CBC: Hct 34, WBC 6.5 Sodium 138 Potassium 3.4 (previous 3.5, 3.6, 3.8) BUN/Cr 22/ 1.1 Glucose 90 LFTs nl TSH 3.23

Abdominal CT…. Abd CT performed in ER 8/06 when presented with abdominal pain Incidental bilateral adrenal hyperplasia

Further labs:… Renin 0.6 Aldosterone 25 Aldosterone/ PRA ratio > 40

Treatment…. Started spironolactone 50 mg qd and referred to hypertension clinic

Next few BP’s 132/68, 152/64, 146/66 Increased spironolactone to 50 mg bid BP’s 142/74, 136/68, 134/62, 150/80, 130/64, 118/70

BP before and after spironolactone Average BP before 150/76 Average BP after 139/69 Referred to HTN clinic