WBR0562

Author	[[PageAuthor::Hardik Patel, M.D.]]
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Emergency Room
Sub Category	SubCategory::Cardiovascular
Prompt	[[Prompt::A 44-year-old man presents to the ER with chest pain and shortness of breath. He has no cough or daytime fatigue. He is a known case of hypertension and chronic kidney disease, the kidney disease is presumed secondary to his hypertension. He has had 3 similar ER visits, and seen a cardiologist for this problem, where he found to be positive for hematuria and cocaine use. On physical examination, he is thin and dyspneic. His BP is 188/98 mm Hg. His in-office blood pressures have been approximately 135-140/80-85 mm Hg, and he reports similar readings when he monitors his own blood pressure, using a self-inflating blood pressure cuff at home. He is on ramipril, metoprolol, furosemide, and clonidine. He is a habitual cocaine abuser. His creatinine has risen a bit more quickly than expected. His EKG shows non-specific ST changes. His lab results are pending. What is the most likely cause of his acute blood pressure elevation?]]
Answer A	AnswerA::Fibromuscular dysplasia
Answer A Explanation	[[AnswerAExp::Incorrect: Fibromuscular dysplasia can be a cause of secondary hypertension, but this patient does not appear to have any findings suggestive of FMD.]]
Answer B	AnswerB::Obstructive sleep apnea
Answer B Explanation	[[AnswerBExp::Incorrect: Obstructive sleep apnea (OSA) can be a cause of secondary hypertension, but this patient does not appear to have any sleep abnormalities.]]
Answer C	AnswerC::Pheochromocytoma
Answer C Explanation	[[AnswerCExp::Incorrect: Pheochromocytoma can be a cause of secondary hypertension, but this patient does not appear to have any findings suggestive of Pheochromocytoma.]]
Answer D	AnswerD::Cocaine abuse
Answer D Explanation	AnswerDExp::'''Correct:''' See explanation.
Answer E	AnswerE::Hyperaldosteronism
Answer E Explanation	[[AnswerEExp::Incorrect: Hyperaldosteronism may cause resistant hypertension, but this patient does not appear to have any electrolyte abnormalities which may be evident in case of hyperaldosteronism.]]
Right Answer	RightAnswer::D
Explanation	[[Explanation::The patient most likely has acute blood pressure elevations and worsening renal function due to his cocaine use. Patients who have hematuria, episodic blood pressure elevations, and stepwise worsening of creatinine in the setting of cocaine abuse should be suspected of this diagnosis. Cocaine use may lead to both acute and chronic forms of kidney disease, as well as cause acute and chronic elevations in blood pressure. Educational Objective: References: ]]
Approved	Approved::Yes
Keyword	WBRKeyword::Cardiovascular effects of cocaine, WBRKeyword::Hypertension
Linked Question	Linked::
Order in Linked Questions	LinkedOrder::