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If it's pheo, the bp rise will be episodic. in this question it's deliberatee inclusion to give 4 readings saying that it's constant rather than episodic. Usually pheo's symptomatic compared to cushings
In Cushings, Obesity could be the only initial presentation followed by other features and the HTN is consistantly high.
It would be good idea to investigate further. I agree with the choice of urine cortisol
Just recommending weight reducing exercise may prove costly later, without proper investigation in a child. I would strongly disagree with the choice A
Comments welcome
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Carefull 60% of Pheo's have stable hypertention! Girls withn Cushings always have some menstral problems.
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well i think pheo is not likely in this case....as its mostly episodic HTN though can be stable... but absence of other positive findings and relative stable HR compared to her BP measurements makes it much less likely
A vs C....24 hr urine cortisol levels are an effective screen for cushings, so rest of the tests wud follow the screening test, and the only reason I wud do it wud be to effectively rule out secondary cause of the HTN as ptt is obese and cushings cud present with HTN with obesity before labelling her essentially hypertensive for life...if screen is negative then wud go for A..
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Captopril???????????????? how we are going to star therapy in 15 YO w/o rule out more causes of HTN...pranav said DD so is no better go first to renal biopsy to rule out whether or not there is kidney damage,make some more test availablefor diagnosis os glomerulonephritis?? i keep going AAA
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Its definitly either B or C.
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The physical examination in hypertensive children is frequently normal except for the BP elevation. The extent of the laboratory evaluation is based on the child's age, history, physical examination findings, and level of BP elevation. The majority of children with secondary hypertension will have renal or renovascular causes for the BP elevation. Therefore, screening tests are designed to have a high likelihood of detecting children and adolescents who are so affected. These tests are easily obtained in most primary care offices and community hospitals. Additional evaluation must be tailored to the specific child and situation. The risk factors, or comorbid conditions, associated with primary hypertension should be included in the evaluation of hypertension in all children, as well as efforts to determine any evidence of target-organ damage.
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Additional Diagnostic Studies for Hypertension
Additional diagnostic studies may be appropriate in the evaluation of hypertension in a child or adolescent, particularly if there is a high degree of suspicion that an underlying disorder is present. Such procedures are listed in Table 7. ABPM, discussed previously, has application in evaluating both primary and secondary hypertension. ABPM is also used to detect white-coat hypertension.
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Weight reduction is the primary therapy for obesity-related hypertension. Prevention of excess or abnormal weight gain will limit future increases in BP.
Regular physical activity and restriction of sedentary activity will improve efforts at weight management and may prevent an excess increase in BP over time.
Dietary modification should be strongly encouraged in children and adolescents who have BP levels in the prehypertensive range as well as those with hypertension.
Family-based intervention improves success.
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Indications for antihypertensive drug therapy in children include secondary hypertension and insufficient response to lifestyle modifications.
Recent clinical trials have expanded the number of drugs that have pediatric dosing information. Dosing recommendations for many of the newer drugs are provided.
Pharmacologic therapy, when indicated, should be initiated with a single drug. Acceptable drug classes for use in children include ACE inhibitors, angiotensin-receptor blockers, ß-blockers, calcium channel blockers, and diuretics.
The goal for antihypertensive treatment in children should be reduction of BP to <95th percentile unless concurrent conditions are present, in which case BP should be lowered to <90th percentile.
Severe, symptomatic hypertension should be treated with intravenous antihypertensive drugs.
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