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Difficulty: MediumDiagnostic Workup and Test Sequencing

Match each clinical presentation of a patient with severe or resistant hypertension to the most appropriate next diagnostic test in their workup sequence.

  • A 42-year-old man presenting to the clinic with resistant hypertension, severe episodic headaches, resting tachycardia, and unpredictable episodes of profuse diaphoresis.Measurement of plasma fractionated metanephrines
  • A 65-year-old man presenting to the emergency department with acute tearing chest pain radiating to the back, unequal pulses in the upper extremities, and a hypertensive emergency.Computed tomography angiography of the chest and abdomen
  • A 38-year-old woman presenting to the outpatient clinic with treatment-resistant hypertension, persistent fatigue, unexplained muscle weakness, and profound spontaneous hypokalemia on a basic metabolic panel.Determination of plasma aldosterone concentration to plasma renin activity ratio
  • A 45-year-old man presenting with progressive weight gain, uncontrolled hypertension, central adiposity, wide purple striae on the abdomen, and proximal muscle weakness.Overnight low-dose dexamethasone suppression test

Answer

The pheochromocytoma presentation matches with plasma fractionated metanephrines. The acute aortic dissection presentation matches with CT angiography of the chest and abdomen. The primary hyperaldosteronism presentation matches with the plasma aldosterone-to-renin activity ratio. The Cushing syndrome presentation matches with the overnight low-dose dexamethasone suppression test.
Correct matching pairs the clinical syndrome with its guideline-indicated first-line screening test. Pheochromocytoma is screened via plasma free metanephrines. Acute aortic dissection is an emergency assessed via CT angiography of the chest and abdomen. Primary hyperaldosteronism requires the aldosterone-to-renin ratio. Cushing syndrome is evaluated initially with an overnight dexamethasone suppression test or 24-hour urine free cortisol.

Step-by-Step Solution

1
Analyze the first presentation (episodic headaches, tachycardia, diaphoresis) to identify the underlying syndrome.
The clinical picture points to a pheochromocytoma.
These symptoms reflect catecholamine excess, necessitating biochemical testing for catecholamine metabolites.
2
Evaluate the second presentation (acute tearing chest pain, unequal pulses, hypertensive emergency).
The findings are characteristic of an acute aortic dissection.
A life-threatening vascular emergency requires immediate anatomical imaging rather than delayed outpatient biochemical screening.
3
Assess the third presentation (resistant hypertension with profound spontaneous hypokalemia).
This presentation strongly suggests primary hyperaldosteronism.
Aldosterone excess leads to sodium retention and potassium wasting, requiring biochemical confirmation via aldosterone and renin levels.
4
Review the fourth presentation (central adiposity, purple striae, proximal weakness).
These signs point to Cushing syndrome.
Hypercortisolism is best screened initially with tests that evaluate the hypothalamic-pituitary-adrenal axis feedback loop.

Key Concept

Secondary causes of hypertension and hypertensive emergencies require specific initial screening tests tailored to the patient's most prominent clinical manifestations and the acuity of their presentation.
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Topics

Diagnostic Workup and Test Sequencing

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