A clinic focuses on the evaluation and management of severe and resistant hypertension. Match each patient's clinical presentation with the most appropriate initial diagnostic test for their suspected secondary cause of hypertension.
- A 45-year-old man with persistent hypertension despite maximum tolerated doses of amlodipine, lisinopril, and chlorthalidone. Routine laboratory results reveal a serum potassium level of 2.9 mEq/L.Early morning plasma aldosterone concentration to plasma renin activity ratio
- A 38-year-old woman evaluated for episodic spells of pounding headaches, profuse nonexertional sweating, and tachycardia, accompanied by blood pressure elevations up to 210/110 mm Hg.Measurement of plasma fractionated free metanephrines
- A 26-year-old woman presenting with new-onset hypertension of 175/105 mm Hg and a subauricular bruit appreciated on physical examination.Computed tomography angiography of the abdomen and pelvis
- A 48-year-old woman with difficult-to-control hypertension, recent onset of type 2 diabetes mellitus, easy bruising, and an unexplained osteoporotic vertebral compression fracture.Overnight 1-mg low-dose dexamethasone suppression test
Answer
The scenarios match their respective diagnostic tests as follows: The patient with hypokalemia requires an aldosterone-to-renin ratio; the patient with episodic headaches and sweating requires plasma free metanephrines; the young woman with a bruit requires CT angiography; and the patient with metabolic and bone abnormalities requires a dexamethasone suppression test.
Each patient's clinical presentation aligns perfectly with a specific secondary cause of hypertension (primary hyperaldosteronism, pheochromocytoma, fibromuscular dysplasia, and Cushing syndrome, respectively), dictating the targeted initial diagnostic tests provided in the correct pairs.
Step-by-Step Solution
Key Concept
Identification of distinct secondary causes of hypertension and selection of their appropriate initial screening modalities.