Rising home BP measurements in a hypertensive woman

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Ms. M, age 49, presented to our outpatient clinic for cardiovascular evaluation and medication counseling following a recent rise in her home-monitored BP readings. She had no complaints of fever, headache, dizziness, double vision, neck pain, tinnitus, nocturia, excessive thirst, or muscle cramps.

The patient reported that since her hypertension was first diagnosed at age 28, her BP had been under moderate control. Current daily medications included lisinopril 10 mg, hydrochlorothiazide 50 mg, a multivitamin, and calcium citrate 500 mg. The patient reported no allergies—environmental or medicinal—and no history of diabetes, stroke, MI, transient ischemic attack (TIA), chest pains, or palpitations.

Ms. M, who was employed as a real estate agent, was unmarried and had never been pregnant. Mindful of her health, she exercised at the gym for an hour once a week. She did not smoke and stated she was a social drinker—enjoying two to three glasses of wine per week. Both her parents died from cardiovascular disease—her mother at age 67 from an acute MI and her father at age 70 from a stroke. Ms. M's 45-year-old brother had type 2 diabetes mellitus.

1. PHYSICAL EXAMINATION

The patient presented as an alert and otherwise healthy adult female in no acute distress. She stood 5 ft 4 in tall and weighed 147 lb. Vital signs obtained by my assistant were temperature 98.8ºF, BP 156/90 mm Hg (left arm, sitting), heart rate 124 beats per minute. A repeat BP obtained by me was 148/88; heart rate was regularly regular at 119 beats per minute. The patient's abdomen was soft, nontender, and without scars or masses. Bowel sounds were heard on auscultation in all quadrants; there was no organomegaly. The remainder of her examination was normal.

A complete blood count and an electrolyte panel were unremarkable. The patient's biochemistry profile is summarized in Table 1.Ms. M's biochemsitry profile

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