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CHIEF COMPLAINT

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PATIENT Image not available.

Mr. U is a 48-year-old man with a BP of 165/90 mm Hg.

Image not available. What is the differential diagnosis of hypertension? How would you frame the differential?

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CONSTRUCTING A DIFFERENTIAL DIAGNOSIS

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First, what is normal BP, and when is a patient hypertensive? The first step is accurately measuring the BP. Table 23-1 summarizes guidelines for obtaining valid BP measurements.

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Table Graphic Jump Location
Table 23-1.Guidelines for measuring BP.
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Consensus guidelines classify BP as follows, based on the mean of 2 seated BP measurements on each of 2 or more office visits:

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  1. Optimal: systolic BP (SBP) < 120 mm Hg and diastolic BP (DBP) < 80 mm Hg

  2. Normal: SBP 120–129 mm Hg and DBP 80–84 mm Hg

  3. High normal: SBP 130–139 mm Hg or DBP 85–89 mm Hg

  4. Grade 1 hypertension: SBP 140–159 mm Hg or DBP 90–99 mm Hg

  5. Grade 2 hypertension: SBP 160–179 mm Hg or DBP 100–109 mm Hg

  6. Grade 3 hypertension: SBP ≥ 180 mm Hg or DBP≥ 110 mm Hg

  7. Isolated systolic hypertension: SBP ≥ 140 mm Hg and DBP < 90 mm Hg

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Hypertension is either primary (essential) or secondary (resulting from a specific identifiable cause). Causes of secondary hypertension can be organized using an organ/system framework:

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  1. Primary (essential) hypertension

  2. Secondary hypertension

    1. Endocrine

      1. Primary aldosteronism

      2. Pheochromocytoma

      3. Thyroid disease

      4. Hyperparathyroidism

      5. Cushing syndrome

    2. Renal

      1. Chronic kidney disease (CKD)

      2. Acute kidney injury

    3. Vascular

      1. Renovascular disease

      2. Coarctation of the aorta

    4. Pulmonary: sleep apnea

    5. GI: obesity

    6. Drug-induced or drug-related

      1. Prolonged corticosteroid therapy

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