A 42-year-old woman comes to the office for evaluation of elevated blood pressure. She says, "I checked my blood pressure on a machine at the pharmacy, and it was 160/90 mm Hg. The pharmacist said I should see a doctor." The patient has no history of hypertension and has had no chest pain, headache, or focal weakness or numbness. She notes occasional episodes of pain in her flanks, which she ascribes to muscle tension. The patient has had several urinary tract infections over the course of her life but has no chronic medical problems and takes no medication regularly. She does not use tobacco, alcohol, or illicit drugs. The patient is married and has a son. Her mother has hypertension, her father died at an early age in a motor vehicle collision, and her uncle has renal failure and receives dialysis. Blood pressure is 156/94 mm Hg on the right arm and 152/96 mm Hg on the left arm. Pulse is 80/min and respirations are 16/min. Jugular venous pressure is within normal limits. Breath sounds are normal bilaterally with no crackles. Point of maximal impulse is displaced to the left and down. Heart sounds are normal with no murmur or gallops. The abdomen is soft with bilateral flank fullness. Bowel sounds are active. Laboratory results are as follows. Urinalysis shows dysmorphic erythrocytes and mild proteinuria. ECG shows left ventricular hypertrophy with nonspecific ST-T wave changes.
Which of the following is the best next step in management of this patient?

Question

A 42-year-old woman comes to the office for evaluation of elevated blood pressure.  She says, "I checked my blood pressure on a machine at the pharmacy, and it was 160/90 mm Hg.  The pharmacist said I should see a doctor."  The patient has no history of hypertension and has had no chest pain, headache, or focal weakness or numbness.  She notes occasional episodes of pain in her flanks, which she ascribes to muscle tension.  The patient has had several urinary tract infections over the course of her life but has no chronic medical problems and takes no medication regularly.  She does not use tobacco, alcohol, or illicit drugs.  The patient is married and has a son.  Her mother has hypertension, her father died at an early age in a motor vehicle collision, and her uncle has renal failure and receives dialysis.  Blood pressure is 156/94 mm Hg on the right arm and 152/96 mm Hg on the left arm.  Pulse is 80/min and respirations are 16/min.  Jugular venous pressure is within normal limits.  Breath sounds are normal bilaterally with no crackles.  Point of maximal impulse is displaced to the left and down.  Heart sounds are normal with no murmur or gallops.  The abdomen is soft with bilateral flank fullness.  Bowel sounds are active.  Laboratory results are as follows.  Urinalysis shows dysmorphic erythrocytes and mild proteinuria.  ECG shows left ventricular hypertrophy with nonspecific ST-T wave changes. 
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient has evidence of left ventricular hypertrophy on examination (eg, displaced point of maximal impulse) and on ECG, suggesting long-standing hypertension. Given the presence of bilateral flank pain/fullness and a family history of end-stage renal disease, the hypertension is likely due to underlying autosomal dominant polycystic kidney disease (ADPKD). ADPKD is an inherited disorder with a prevalence of approximately 1 in 500. Hypertension is a common early manifestation. Patients also frequently develop hematuria, proteinuria, and flank pain. Most patients with ADPKD have progressive renal insufficiency as they age; approximately 50% require renal replacement therapy by age 60. Patients with suspected ADPKD should be screened with renal ultrasound. The presence of enlarged kidneys with multiple bilateral cysts is usually diagnostic. multiple bilateral cysts (Choice A) Pheochromocytoma can also cause secondary hypertension and is usually diagnosed with urine and plasma metanephrine testing. Patients with pheochromocytoma typically have paroxysmal hypertension, diaphoresis, headaches, and sinus tachycardia. This patient with flank pain and fullness is more likely to have ADPKD. (Choice B) Patients with essential hypertension are often treated with lifestyle modifications. This patient with evidence of long-standing hypertension at a relatively young age and flank fullness should undergo further evaluation with renal ultrasonography. (Choice C) Primary hyperaldosteronism can also cause secondary hypertension and is typically diagnosed when plasma renin levels are very low (often undetectable) and aldosterone levels are inappropriately high. Primary hyperaldosteronism is often associated with hypokalemia. (Choice E) Home blood pressure monitoring is often used when a true diagnosis of hypertension is unclear (eg, white coat hypertension). This patient with signs of long-standing hypertension (likely left ventricular hypertrophy), bilateral flank pain/fullness, and urinalysis abnormalities should undergo renal ultrasound to examine for ADPKD. Educational objective: Autosomal dominant polycystic kidney disease is an inherited disorder characterized by multiple bilateral renal cysts. Patients are often asymptomatic, but many develop hypertension, hematuria, proteinuria, renal insufficiency, and/or flank pain. Diagnosis is usually made by renal ultrasound.

A 42-Year-Old Woman Comes to the Office for Evaluation of Elevated