darkhouse but wy we would go for captopril renography? not angiography(gold standard) why not doppler as a initial test? help?
I think that A sounds most correct, because sensitivity and specificity of Duplex and captopril angiography are almost the same, about 80%. At the same time it is easier to perform DUPLEX. Moreover according to patient age, she most probably has fibrodisplasia of her arteries, that will be easily seen by DUPLEX. Angiography is invasive procedure, so I think it will ne better to live it as a reserve method.
It will be nice to hear the original answer
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(D) Captopril renography
Explanation:
This case illustrates a patient with possible bilateral or unilateral renal artery stenosis (RAS). Clues pointing to this patient as having a cause of secondary hypertension are an onset below the age of 30 and the fact that RAS is the most common cause of secondary hypertension. In the absence of specific findings of one of the other causes of hypertension on history or physical, RAS should be the first diagnosis to pursue. Although she does not have an abdominal bruit, this may be because she is obese and you cannot adequately auscultate the abdomen. Starting lisinopril is potentially problematic. If the patient has bilateral RAS, ACE inhibitors can cause a precipitous decline in renal function. The BUN and creatinine can be normal in a patient with unilateral RAS because a single normal kidney will keep these tests normal.
The Doppler (duplex ultrasound) is both minimally invasive and inexpensive. Because of her obesity, however, it will lack accuracy. Magnetic resonance imaging (MRI) is not the correct answer; magnetic resonance angiography (MRA) is the study that will show the stenosis. Captopril nuclear renogram will have >85 to 90% sensitivity and would be more accurate than the Doppler in an obese patient. Angiography is the gold standard but would not be done until one of the other noninvasive tests just mentioned had been done or was inconclusive.
Had this patient not been obese, then the first step is the Doppler Duplex. Is that correct?