Can you make the diagnosis?

[Mortal_Lessons]

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20 y.o male wakes up with nose bleed one morning and visits an emergency room. Blood pressure is sky high (220/110). No individual history of high bp, but has a family history of high bp. Doctor prescribes patient to b-blockers (propanol ) and bp is now stable at 140/90, yet this is still higher than the patient's pre-nosebleed bp. Doctor suspects narrowing of renal artery. MRI disproves this suspicion. Patient is now on dietary restrictions from salt, etc, continues taking b-blocker, yet bp is still high and his heart rate is also above normal. Also, he complains of heart rate shooting up when he walks up one step. What's your take on this situation, or what are some of the next questions that need to be asked? (Met this kid tonight playing basketball at the gym. He looks healty and normal (maybe a bit pudgy). He had to sit out b/c his heart rate was too high. I'm going to med school next year and interested in solving this puzzle before then.) Thanks.

 

[salmonella]

Sounds like pheochromocytoma

 

[indo]

Does he become out of breath while playing basketball or just the high HR?

He must have too much sympathetic output or too little parasympathetic output. I'd want to see the hypothalamus and medulla if renal is ruled out.

 

[Big Ben]

This kid needs the full w/u for secondary HTN. Pheo is still unlikely despite the history for all comeres.. needs basic labs, w/u for hyperaldo, TSH, etc. etc.

Coarctation needs r/o and can be missed along the way. Someone this young should get an echo. Needs screened for substance abuse.

Finally, an MRA is not helpful in this age group. RAS in a 20 year old is unlikely to be atherosclerotic. He would have FMD which requries either CT angio (still not a great test) or generally digital subtraction angio. Someone this young merits all of this.

 

[RADRULES]

MRA can diagnose FMD - unless it is read by a cardiologist.

Tx is angioplasty without stent - easy tx for htn in young patient.

 

[tum]

you got a medical history history from him on the basketball court? we used to just trash talk.

anyways, not to be that guy, but have you asked him about recreational drugs? i know he was controlled with b-blockers which is a little off, but hey you never know.

but you need an endocrine work up. pheo, sure maybe. also think about hyperthy (he is pudgy so go figure), cushing's, i guess conn's although that probably would have shown up on his lytes (ie K).

for fmd, gold standard of diagnosis is digital substraction angiography. you can try duplex, CTA, or MRA but although they're specific, for each sensitivity is around 60%. (vasbinder, annals of internal medicine - 2004) with such a young guy, and a problem that's relatively easy to correct, i'd want the gold standard to be sure.

in any case, as with all of the other 'real life' questions i've seen on sdn, he needs to see a real life doctor, instead of an online student-doctor.


by the way, radrules--you are such a troll : )

 

[Mortal_Lessons]

Hey everyone,

I appreciate your responses. Sorry my reply wasn't sooner; I just figured this post was dead because no one had responsed in a few days. I do not know much about this student, so everything I described in my first post is pretty much all I got to know about him that night during the basketball game. I do appreciate your input and although most of it is gibberish to me, I've wikipedia'd some of your medical terms and enjoyed reading through the articles, especially:

Sounds like pheochromocytoma

I wanted to try and address a few of your posts to give you a better idea of the problem.

Does he become out of breath while playing basketball or just the high HR?

He must have too much sympathetic output or too little parasympathetic output. I'd want to see the hypothalamus and medulla if renal is ruled out.

He didn't seem to be running out of breath and his only complaint was that his HR was getting too high. I noticed that he would reach up and feel the pulse from his carotid artery in his neck.

This kid needs the full w/u for secondary HTN. Pheo is still unlikely despite the history for all comeres.. needs basic labs, w/u for hyperaldo, TSH, etc. etc.

Coarctation needs r/o and can be missed along the way. Someone this young should get an echo. Needs screened for substance abuse.

Finally, an MRA is not helpful in this age group. RAS in a 20 year old is unlikely to be atherosclerotic. He would have FMD which requries either CT angio (still not a great test) or generally digital subtraction angio. Someone this young merits all of this.

I think I may have asked him if he did drugs and he replied, "No." I don't know him that well, so a drug test may be in order.

MRA can diagnose FMD - unless it is read by a cardiologist.

Tx is angioplasty without stent - easy tx for htn in young patient.

Not sure what this means.

you got a medical history history from him on the basketball court? we used to just trash talk.

anyways, not to be that guy, but have you asked him about recreational drugs? i know he was controlled with b-blockers which is a little off, but hey you never know.


but you need an endocrine work up. pheo, sure maybe. also think about hyperthy (he is pudgy so go figure), cushing's, i guess conn's although that probably would have shown up on his lytes (ie K).

for fmd, gold standard of diagnosis is digital substraction angiography. you can try duplex, CTA, or MRA but although they're specific, for each sensitivity is around 60%. (vasbinder, annals of internal medicine - 2004) with such a young guy, and a problem that's relatively easy to correct, i'd want the gold standard to be sure.

in any case, as with all of the other 'real life' questions i've seen on sdn, he needs to see a real life doctor, instead of an online student-doctor.


by the way, radrules--you are such a troll : )

Haha, I agree about a real doctor instead of a student-doctor. He is seeing the chief of cardiology at my institution's health center, so he's supposedly in great hands. I'm just confused b/c it seems like his condition has perplexed even his cardiologist. Regarding the recreational drugs, this kid didn't come off as a user of anything over and above pot, but like I said earlier, I don't really know him. And yeah, we usually do talk trash, but this kid complained that he couldn't get back in the game b/c his heart rate was going too fast and that's what got us talking about his health.

Anyways, I appreciate all the feedback. Thanks everyone.

 

[(Pants)^2]

nose bleed was likely secondary to his HTN. Unless you think of some weird Rheum dx like lupus (rare in men) or Wegners...