Patient History, Symptoms and Signs

A 35-year-old, White woman presents at the clinic with hypertension that has been managed since her diagnosis five years ago, but that has remained uncontrolled, despite numerous changes to her multi-drug regimen. Her elevated blood pressure (BP) was first noted when she underwent a tubal ligation, six weeks after a normal pregnancy. It has remained elevated ever since.

At the clinic visit, her chief complaints are decreased libido and fatigue. She occasionally has frontal headaches, muscle cramps, and some dyspnea on exertion. She used to run eight miles, four times a week, until a year ago when she had three episodes of exertional-type, left-sided chest pain that radiated to her neck. The work-up for her chest pain included a normal cardiolyte stress test with an ejection fraction of 64%. She no longer exercises because of fatigue.

She says her BP seems worse during menstruation. Her daily average resting home BP is 150-165/90-100 mmHg on her current regimen of irbesartan 300 mg QD, diltiazem hydrochloride 180 mg QD, atenolol 100 mg QD, hydrochlorothiazide 12.5 mg, potassium chloride 80 mEq QD, and a multivitamin tablet daily.

Her past medical and surgical history includes hypertension, hypokalemia, mitral valve prolapse, intermittent sinusitis, ankle surgery, and tubal ligation. She has had two normal pregnancies.

The patient is a bookkeeper in a small, rural town. She stopped smoking a year ago after a four pack-year history and does not drink alcohol. There is no family history of hypertension or other significant cardiovascular disease. She is married and has two healthy children.

Physical examination reveals she is of average build (weight 144 lbs) and height (5’ 6”) with a BMI of 23 and a right arm sitting BP of 158/94 mmHg, with no orthostasis. She has a regular pulse of 68/min. Her funduscopy shows only arteriovenous narrowing with sharp disc margins.

Other findings are:

• No carotid or renal bruit
• Normal jugular venous pressure
• Symmetrical and normal peripheral pulses
• Normal heart rate and rhythm
• Apical impulse
• A 2/6 systolic ejection murmur, best heard at the left sternal border
• Nonpalpable aorta
• No peripheral edema.

Remaining systemic examination is unremarkable, and 24-hour ambulatory blood pressure monitoring confirms that her BP is raised most of the time.