Let's start with a clinical case.
A 34-year-old woman is seen in her primary care physician's office for her annual checkup.
She reports no new history and no new medications, other than her multivitamin that she takes daily.
On review of systems, however, she notes that she's had new-onset headaches,
maybe about 1-2 times weekly, and she describes pulsatile tinnitus.
So, that means she's hearing a wooshing sound, kind of a rhythmic tone, almost like a heartbeat.
Her exam is remarkable for a blood pressure of 170/90 mmHg
and auscultation of a left carotid and abdominal bruit.
Her blood pressure measurement was repeated after having her sit in a quiet dark room for 10 minutes
but she remained hypertensive at 172/88 mmHg.
Her laboratory data were significant for a normal creatinine at 0.8 mg/dL,
normal electrolytes, and her urinalysis was unremarkable.
So, the question is, does this woman most likely have primary hypertension or secondary?
And if so, what is the next step in establishing the diagnosis?
Let's go through our clinical case and see if we've got some clues.
If we look at this young lady, she has a relatively young age of hypertension onset
so that is suspect for a secondary cause.
She also describes headaches and pulsatile tinnitus.
That in combination with a new onset hypertension, a left carotid bruit, an abdominal bruit,
and a female patient, very highly suggestive for something called fibromuscular dysplasia.
So, the answer to our question, does she most likely have primary or secondary?
I would say she has secondary hypertension.
What's the next step that we want to do in order to establish a diagnosis?
If we're thinking about fibromuscular dysplasia, we wanna look at renal artery imaging.