cirus
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A 50-year-old man is evaluated for poorly controlled hypertension. His blood pressure has been elevated for 12 years and remains between 150/105 mm Hg and 170/105 mm Hg despite the use of multiple medications. He also has poor exercise tolerance and fatigue and often falls asleep in the afternoon. Medications are atenolol, 50 mg/d; amlodipine, 10 mg/d; and hydrochlorothiazide, 25 mg/d.
On physical examination, blood pressure is 168/110 mm Hg. He is obese and appears plethoric. The remainder of the examination is normal.
Laboratory Studies
Glucose fast 102 mg/dL (5.66 mmol/L)
BUN 20 mg/dL (7.14 mmol/L)
Creatinine 1.4 mg/dL (123.79 μmol/L)
Sodium 140 meq/L (140 mmol/L)
Potassium 3.9 meq/L (3.9 mmol/L)
Bicarbonate 25 meq/L (25 mmol/L)
Cholesterol 220 mg/dL (5.69 mmol/L)
Triglycerides 190 mg/dL (2.15 mmol/L)
High-density lipoprotein cholesterol 37 mg/dL (0.96 mmol/L)
Which of the following is the most likely cause of this patient's resistant hypertension?
a. Renovascular hypertension
b. Primary hyperaldosteronism
c. Pheochromocytoma
d. Type 2 diabetes mellitus
e. Sleep apnea syndrome
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| doc_clotaire
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E) Sleep apnea syndrome
Clues -----------------
Obese , phethoric ( may be secondary to Polycythemia ) , daytime sleepiness and uncontrolled HT
May be I am wrong but that would be my best call 
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| DeltaF508
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E) Sleep apnea; clues: obese, plethoric secondary to polycythemia which is secondary to hypoxia, daytime sleepiness, uncontrolled HTN.
Not DM2: look at fasting glucose
Not Pheo: history doesn't fit
Not Renovascular: BUN/Cr don't appear so elevated, plus no sign of hyperaldosteronism from looking at electrolytes
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| Justice
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Pleased to agree on E) Sleep apnea syndrome
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| sailing boat
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agreed with e
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| prathapdoctor
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by looking at the history given, it looked like hypothyroidism leading to sleep apnea.
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| doyoudig
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any comment on r/o A from lab values??
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| cirus
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ur all absolutely right..
there is the explaination:
Sleep apnea syndrome may contribute to resistant hypertension as well as to increased cardiovascular and cerebrovascular disease risk. Affected patients may have excessive fatigue and may fall asleep while driving or working. This condition has a higher prevalence in overweight men. The pathogenesis of sleep apnea syndrome is complex and linked to obesity, insulin resistance, and increased sodium retention. Several studies have shown that patients with sleep apnea syndrome have increased activity of the sympathetic nervous system, which also occurs in obesity. Coexistent insulin resistance and impaired glucose tolerance also may be present in these patients.
Renovascular hypertension may cause resistant hypertension but is less common than sleep apnea. Atherosclerotic renovascular hypertension usually develops in older patients, whereas fibromuscular dysplasia often presents in younger patients and is more common in women. Primary aldosteronism may be present in as many as 10% of patients with resistant hypertension and is included in the differential diagnosis. However, this condition is less likely in a patient who takes hydrochlorothiazide and has a normal potassium level.
Pheochromocytoma is a rare form of hypertension mediated by excess catecholamines. This condition causes palpitations, diaphoresis, tremor, flushing, and headaches. Diagnosis of pheochromocytoma may be difficult, and the clinical manifestations vary significantly. This patient's presentation is consistent with this condition, but sleep apnea is more likely because it is more common and more likely to be associated with obesity. This patient is at risk for type 2 diabetes mellitus, but his fasting glucose level does not meet the criteria for diabetes. Diabetes is associated with hypertension but is not considered a cause of resistant hypertension.
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