Case of Severe Hypertension and Nephrotic Range Proteinuria
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The presentation of this patient is from the perspective of an emergency department. A 37-year-old man with severe hypertension was referred by a family physician. This is not uncommon where, sometimes, primary care physicians feel uncomfortable managing such patients and refer them to the emergency department for specialist care. After assessment, these patients are usually quickly discharged.
The patient was generally healthy; however, for the last 6 months, he was treated with atenolol 50 mg for hypertension and had headaches, nausea, dizziness, and left flank pains. He had no diarrhea or constipation. He lost about 5 kilograms of weight during this period. He has no family history of hypertension or renal disease.
On examination, he was found to be fully conscious and relaxed, and his blood pressure was 190/126 mm Hg with a pulse rate of 88 bpm and with no respiratory distress. His body mass index was 19.5 kg/m2. There were no alarming findings on fundoscopy. He had clear lungs, normal heart sounds, no abdominal or flank tenderness, no organomegaly, no peripheral edema, and normal peripheral pulses. His calf blood pressure was 232/144 mm Hg, ruling out coarctation of the aorta. He had no neurological deficit and no other findings such as skin rash or purpura.
His electrocardiogram was normal with some voltage criteria for left ventricle hypertrophy; however, at the age of 37 years, this is of questionable significance. His biochemistry showed severe hyponatremia, severe hypokalemia, normal creatinine level, low albumin level, high cholesterol levels, with normal liver function test (Table 1). This certainly changed the perception that he is just one of those patients referred because of his primary physician’s uncertainty in management. He had normal complete blood count and red blood cell morphology. Urine sediment was normal, but dipstick analysis was positive for protein. …