NBME 2: 15-year-old girl is brought - khushigrover

[ArchivalUser]

2. 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

CAN anybody plz explain this.........

[ArchivalUser]

why a 14 Y/O has high BP????? the next step in managements would be AAA???? we have rule out ALL the posibilities..so i would go for AAAAA, cause this girl is otherwise asyntomatic, her only issue is obesity and i think that the antecedent of previous UTI is a distractor in the question, happen 1 year ago and was succesfull treated

[ArchivalUser]

I agree that UTI is a distractor , but I wouldn't start treatment yet. we need to find out why she has High BP . I think B looking fopr a Pheochromocytoma?

[ArchivalUser]

I would go for D

The most common cause of increased blood pressure in a child is renal.

This child had UTI 1 year ago. Each episode of UTI puts kidneys at increased risk of scarring.In practice, if renal ultrasound is negative and the blood presssure is high, we should do DMSA scan to see any scarring of the kidneys and also doppler to r/o renal artery stenosis. But as those tests are not given in choices , we should always treat this child's HTN .

The most frequently used medication is Captopril/ ENALAPRIL

Just obesity on 95th centile is very unlikely to cause persistent HTN and moreover, we should treat it to prevent end organ damage.

other comments welcome

[ArchivalUser]

ok-- elisue but tell me what signs of phechromocytoma this patient has????? the blood pressure even is high it is not as higher as in pheochromosytoma,, so I am 100% agree with you and then also could be CCC she is obese so she could have coushing syndrome, obese and hypertensive....but my point is thar this patient is ASYNTOMATIC she has no any symtoms that make us think in BBB or CCCC

[ArchivalUser]

I wud go with C.....before labelling a ptt essentialy hypertensive...rule out sec causes....cushings cud present with obesity

[ArchivalUser]

Hi,

It's really interesting question. If we have to choose between B and C, C is the better option I think as Cushings syndrome can present with Obesity and HTN or she could be using steroids for the sports camp(!!!)

I hope someone will come with more convincing explanation!!

[ArchivalUser]

A.

[ArchivalUser]

hi darkhorse whats up?? cud u pls explain..

[ArchivalUser]

hi ronaldo....nice to see u....have u finished all ur steps....?