View source for WBR0619

{{WBRQuestion
|QuestionAuthor={{Rim}}
|ExamType=USMLE Step 1
|MainCategory=Pathology
|SubCategory=Vascular
|MainCategory=Pathology
|SubCategory=Vascular
|MainCategory=Pathology
|SubCategory=Vascular
|MainCategory=Pathology
|MainCategory=Pathology
|SubCategory=Vascular
|MainCategory=Pathology
|SubCategory=Vascular
|MainCategory=Pathology
|SubCategory=Vascular
|MainCategory=Pathology
|SubCategory=Vascular
|MainCategory=Pathology
|MainCategory=Pathology
|SubCategory=Vascular
|Prompt=A 52 year old man presents to the physician's office for his annual check-up. During history-taking, the patient denies any symptoms and reports he is feeling healthy. Vital signs and full physical examination are only remarkable for an elevated blood pressure. The physician notes that this is not the first time the patient's blood pressure is high in the clinic. Nonetheless, the patient assures the physician that his blood pressure is periodically measured using a calibrated sphygmomanometer by an experienced nurse practitioner at home and is always within normal limits when not in the clinic. A 24-hour Holter monitor is installed and results show that the patient's blood pressure at home are indeed within normal limits. Which of the following is the most likely diagnosis?
|Explanation=White coat hypertension is defined as high blood pressure in the clinic only, while being normal in the out-clinic setting. It is generally considered a benign condition. Nonetheless, accurate diagnosis of white coat hypertension is necessary before reassuring the patient. In this example, the patient reassures the physician that his blood pressure is measured using a calibrated sphygmomanometer by a nurse practitioner. As such, systemic errors due to inaccurate readings at home and the error in measurement technique can both be ruled out. 24-hour monitoring of the patient's blood pressure using a Holter monitor may be appropriate to rule out true hypertension before the diagnosis of white coat hypertension is made.

Educational Objective: 
White coat hypertension is defined as high blood pressure in the clinic only, whereas it normalizes in the out-clinic setting.
|AnswerA=Masked hypertension
|AnswerAExp=Masked hypertension is defined as having high blood pressure in the out-clinic setting. The blood pressure then normalizes when at the physician's clinic. This condition is considered more dangerous than white coat hypertension, because the patients have high blood pressures without being diagnosed. Nocturnal high blood pressure is especially important in masked hypertension.
|AnswerB=Essential hypertension
|AnswerBExp=Essential hypertension is the diagnosis in more than 90% of patients with constantly high blood pressure. It is defined as high blood pressures during several occasions at home and in the  clinic with no underlying etiology despite comprehensive work-up.
|AnswerC=Secondary hypertension
|AnswerCExp=Secondary hypertension is defined as high blood pressure due a systemic cause. Generally, management of the primary cause helps reduce the high blood pressure.
|AnswerD=Pseudohypertension
|AnswerDExp=Pseudohypertension is defined as reading of high blood pressure using the cuff due to increased inflations required to block the brachial artery. Pseudohypertension is seen in patients who have extensive calcifications that prevent the collapse of the artery when being inflated by the sphygmomanometer cuff.
|AnswerE=White coat hypertension
|AnswerEExp=White coat hypertension is defined as high blood pressure in the clinic only, while being normal in the out-clinic setting. It is generally considered a benign condition. Nonetheless, accurate diagnosis of white coat hypertension is necessary before reassuring the patient.
|RightAnswer=E
|WBRKeyword=white, coat, hypertension, secondary, high, blood, pressure, annual, check, up, check-up, essential, primary, pseudohypertension, masked, Holter, monitor, technique
|Approved=No
}}