Severe Hypertension in a 14-Year-Old Boy

Inas H. Thomas, MD

Disclosures

May 31, 2017

Physical Examination and Workup

A review of systems is negative for hearing abnormalities or birthmarks. The patient's vision was last checked as part of his annual physical examination, with no significant findings.

His vital signs are as follows:

  • Blood pressure: 190/110 mm Hg

  • Pulse: 121 beats/min

  • Temperature: 99.2°F

  • Weight: 146 lb 6.2 oz

  • Height: 5 feet 7.16 inches

  • Body mass index: 84th percentile

The patient is an ill-appearing, diaphoretic, anxious young male sitting in bed. No dysmorphic features are noted. His pupils are equal and reactive to light. No photophobia is observed. His sclera is white. His dentition is normal, without caries.

His mucus membranes are moist. No lymphadenopathy or thyromegaly is noted. He has full range of movement in his neck. His abdomen is mildly tender, but his bowel sounds are normal. He is in Tanner stage 3 for puberty. No scoliosis is observed. His extremities have appropriate muscle tone. His skin has no birthmarks or change in pigmentation.

Other laboratory findings are noted in the following table:

Measurement Reference Range Patient's Results at 6 PM
Sodium 132-145 mmol/L 141 mmol/L
Potassium 3.3-5 mmol/L 4.7 mmol/L
Chloride 98-108 mmol/L 106 mmol/L
CO2 20-28 mmol/L 21 mmol/L
Urea nitrogen 5-20 mg/dL 17 mg/dL
Creatinine 0.40-0.90 mg/dL 0.54 mg/dL
Glucose 50-135 mg/dL 99 mg/dL
Calcium 8.4-10.4 mg/dL 9.7 mg/dL
Protein 5.8-8 g/dL 6.7 g/dL
Albumin 3.2-5.2 g/dL 4.3 g/dL
Aspartate aminotransferase 5-60 IU/L 21 IU/L
Alanine aminotransferase ≤ 35 IU/L 25 IU/L
Alkaline phosphatase 90-420 IU/L 228 IU/L
Bilirubin 0.1-1 mg/dL 0.9 mg/dL
Free thyroxine 0.76-1.70 ng/dL 1.22 ng/dL
Thyroid-stimulating hormone 0.30-5.50 mIU/L 3.20 mIU/L
Metanephrine < 0.5 nmol/L 4.03 nmol/L
Normetanephrine < 0.9 nmol/L 3.78 nmol/L
Cortisol 2-18 μg/dL 6.1 μg/dL

Brain CT findings are unremarkable. Abdominal CT reveals a mass in the right adrenal gland (Figure 1).

Figure 1.

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