Table 11: Key Findings in Selected Causes of Secondary Hypertension

Table 11:
Key Findings in Selected Causes of Secondary Hypertension
Condition	History	Physical Examination	Laboratory Findings
Pheochromocytoma	Paroxysmal hypertension, dizziness, palpitations, headache, nausea, vomiting, "sense of doom," worse with abdominal manipulations, postcoital, or with abdominal torsion, episodes of hyper- or hypotension related to anesthesia or surgery. Can have paroxysmal hypertension with beta blockade. Family or personal history suggestive of multiple endocrine neoplasia syndrome.	Flushing or pallor, tachycardia, bounding pulses. May be normotensive or hypertensive on presentation; usually hypertensive during paroxysms; abdominal palpation may incite paroxysm.	Elevated urine and plasma catecholamines.
Renal artery stenosis	Usually hypertension is severe, resistant to drug treatment, and often presents relatively acutely in previously normotensive individuals. Age usually <35 or >55. May have history of renal insufficiency, particularly after administration of an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker. Often a history of vascular disease.	Abdominal bruit or bruits across other vascular beds suggestive of vascular disease.	Duplex ultrasound or angiogram of the renal vessels. Laboratory data may confirm presence of renal insufficiency, often with bland urine.
Hypothyroidism	Dry skin, hair loss, weight gain, constipation, cold intolerance, cognitive slowing, menstrual irregularity. May be asymptotic in elderly.	Round full face, slow speech, hoarseness, muscle weakness, delayed relaxation on reflex testing, cold skin, coarse brittle hair, normal or faint cardiac impulse, cardiac enlargement, bradycardia, edema.	Low thyroid hormone levels, high thyrotropin
Hyperthyroidism	Lability, irritability, palpitations, muscle weakness, weight loss, diarrhea, heat intolerance, menstrual irregularity	Tremor, fine hair, onycholysis, lid lag, proptosis, tachycardia, atrial fibrillation, wide pulse pressure.	Elevated thyroid hormones, suppressed thyrotropin.
Cushing's syndrome	Weakness, weight gain, amenorrhea	Moon facies, acne, supraclavicular fat pad, purple stria on abdomen/thighs, edema	Increased plasma cortisol, increased urinary 17-keto and hydroxysteroids
Coarctation of the aorta	Usually no suggestive clues on history. Occassionally a history of epistaxis, intermittent claudication, dizziness, or headaches.	Diminished pulse/ blood pressure in vessels distal to coarctation (femoral, sometimes left brachial)	Electrocardiogram shows left ventricular hypertrophy, chest radiograph may show notching of lower rib borders, angiography is diagnostic
Hyperparathyroidism	Muscle weakness, nausea, anorexia, constipation, weight loss, polyuria, polydipsia, deafness, parasthesias, bone pain. Suggested by triad of peptic ulcer, urinary calculi, and pancreatitis.	Band keratitis, hypotonia, weakness	Hypercalcemia, hypophosphatemia, hypercalciuria, elevated alkaline phosphatase
Hyperaldosteronism	Often none. Weakness, paralysis, paresthesias	Weakness. Chvostek's or Trousseau's sign	Hypokalemia or low-normal potassium
Renal parenchymal disease.	Varies, from none to overt uremia. May have history of previous renal disease, diabetes, previous urinary tract infections, abdominal surgeries, prostate disease, or family history of polycystic kidney or other renal disease. Many drugs can cause or worsen renal disease.	Varies. Weakness, anorexia, weight changes, edema, palpable enlarged kidneys	Urinalysis may reveal blood, protein or leukocytes. Sediment examination may reveal casts, oval fat bodies, or dysmorphic cells; however, completely bland sediment does not exclude renal disease Proteinuria should be quantified with 24-hour urine. Electrolytes reveal elevated blood urea nitrogen or creatinine in many, although calculation of creatinine clearance may be needed in the elderly or in patients with low muscle mass to identify those with normal serum creatinine but reduced glomerular filtration rate. Renal ultrasound, renal biopsy, and urine electrolytes may assist.

Return to Initial Evaluation of Blood Pressure Chapter