bluestar
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6.
A 15-year-old girl is brought to the physician 3 months after she had a blood pressure of 150/95 mm Hg at a routine examination prior to participation in school sports. She is asymptomatic and has no history of serious illness. Twelve months ago, she was diagnosed with a urinary tract infection and treated with oral trimethoprim-sulfamethoxazole. She currently takes no medications. Subsequent blood pressure measurements on three separate occasions since the last visit have been: 155/94 mm Hg, 145/90 mm Hg, and 150/92 mm Hg. She is at the 50th percentile for height and 95th percentile for weight. Her blood pressure today is 150/90 mm Hg confirmed by a second measurement, pulse is 80/min, and respirations are 12/min. Examination shows no other abnormalities. Her hematocrit is 40%. Urinalysis is within normal limits. Cardiac and renal ultrasonography shows no abnormalities. Which of the following is the most appropriate next step in management?
A
)
Exercise and weight reduction program
B
)
Measurement of urine catecholamine levels
C
)
Measurement of urine corticosteroid levels
D
)
Captopril therapy
E
)
Hydrochlorothiazide therapy
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| tamar
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B? although I marked D on the test as I remember
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| chemamr
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i think itīs B.
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| bobby
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i will choose C (obesity + htn ...... ) there can be some abnomalities with her adrenal cortex
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| bluestar
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you think it's Cushing?
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| chemamr
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i think itīs the only explanation, bobby thinks itīs a Cushing Sx.
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| tamar
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I think it's pheochromocytoma, HTN could be the first sign of it
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| intern_doc
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Agree...C...cushing.....
she is obese + htn...
pheo ...have to be episodic...this is constant
this Q is tricky as hell
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| bluestar
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in case of this girl, she can only have hyperplasia/adenoma of pituitary, not that of adrenal gland, cuz renal u/s is normal. I think renal u/s covers adrenal gland as well, right?
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| mani
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i think USG is not senstive/specific for adrenals, we would need CT or MRI
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| chemamr
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itīs not a clear question. Pheocromocytoma can present with constant HTN (not uncommonly). USG is not very sensitive for adrenals, itīs better a CT or MRI, so that result of the USG isnīt very reliable. I think itīs B or C. The kid is obese but not only for this she has a Cushing Sx. 
I donīt know the answer. Is there any answer given??
Anyway, if this were your patient, there isnīt any problem, you could ask her a 24h urine for cortisol or a dexamethasone suppresion test or 24 h urine for catecolamines. 
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| aliakram
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Why cant it be A
The question also says examinations reveals no other abnormality, and clearly cushing has other abnormalities on P/E
Starting with drugs aint the first line.
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| chemamr
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i think maybe we should rule out a secondary cause of the HTN, which is the most probable cause.
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| alenka
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i think the answer is B,because:
1.if it was CAH-urinalysis would be abnormal,physical would be abnormal.
2.if it was cushing-the physical would be grossly abnormal for one,and for two-the first test you do if you suspect cushing-dexamethazone supression test,low dose,and urine cortisole is only used for confirming.
3.for pheochromocytoma,which presents like the above patient,the best screening test would be urine catecholamine test.
seems like a good reasoning,huh?
but i'm still in doubts......need to know for sure
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| aliakram
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http://www.guideline.gov/summary/summary.aspx?vie...
according this also. Secondary causes are checked if pt is 95th percentile plus . Evaluation start with history and physical. In the Q at hand it is clear that pt has no real physical feature of Pheochromocytoma (no need doin catchol....such pt r usually thin in real life...these r catabolic hormones), Urinary steroid can be debated considering cushing can happen but here again its the physical feature which is not there, Now therapies aint first line. So my wild guess is either C or A.
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| dr.vasim
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BRAVO Mr.aliakram.. U r RIGHT.
A 15-year-old girl is brought to the physician 3 months after she had a blood pressure of 150/95 mm Hg at a routine examination prior to participation in school sports. She is asymptomatic and has no history of serious illness. Twelve months ago, she was diagnosed with a urinary tract infection and treated with oral trimethoprim-sulfamethoxazole. She currently takes no medications. Subsequent blood pressure measurements on three separate occasions since the last visit have been: 155/94 mm Hg, 145/90 mm Hg, and 150/92 mm Hg. She is at the 50th percentile for height and 95th percentile for weight. Her blood pressure today is 150/90 mm Hg confirmed by a second measurement, pulse is 80/min, and respirations are 12/min. Examination shows no other abnormalities. Her hematocrit is 40%. Urinalysis is within normal limits. Cardiac and renal ultrasonography shows no abnormalities
so now comin to ht 140-160cm n wt 70-80. therfore the main problem is WT. first reduce the WT then go fr othertests n managmnts.
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| dr.vasim
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BRAVO Mr.aliakram.. U r RIGHT.
A 15-year-old girl is brought to the physician 3 months after she had a blood pressure of 150/95 mm Hg at a routine examination prior to participation in school sports. She is asymptomatic and has no history of serious illness. Twelve months ago, she was diagnosed with a urinary tract infection and treated with oral trimethoprim-sulfamethoxazole. She currently takes no medications. Subsequent blood pressure measurements on three separate occasions since the last visit have been: 155/94 mm Hg, 145/90 mm Hg, and 150/92 mm Hg. She is at the 50th percentile for height and 95th percentile for weight. Her blood pressure today is 150/90 mm Hg confirmed by a second measurement, pulse is 80/min, and respirations are 12/min. Examination shows no other abnormalities. Her hematocrit is 40%. Urinalysis is within normal limits. Cardiac and renal ultrasonography shows no abnormalities
so now comin to ht 140-160cm n wt 70-80. therfore the main problem is WT. first reduce the WT then go fr othertests n managmnts.
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| dr.vasim
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anywez i forgot to specialize the line URINANALYSIS within normal limits.
other point in C is in cushings thers smthn else(clinical Features) which may bring us to conclusion of opting test with corticds.
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