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A 38-year-old woman presented to her local clinic for recurrent episodes of headache of several weeks' duration. Evaluation revealed a blood pressure of 202/136 mm Hg. The patient was prescribed 37.5 mg of triamterene with 25 mg of hydrochlorothiazide (1 tablet) twice daily and 50 mg of atenolol once daily.
Her blood pressure remained elevated, and her headaches persisted. She was referred to the hypertension clinic for further management.
The patient's medical history was remarkable for preeclampsia during her second pregnancy 9 years previously. She smoked half a pack of cigarettes per day for 15 years. Her alcohol use was limited to social gatherings and consisted of 1 to 2 drinks monthly. She exercised regularly and had a balanced low-salt diet. Essential hypertension was common on her maternal side.
On physical examination, the patient's blood pressure was 172/100 mm Hg (both arms), and her heart rate was 90 beats/min. Findings on funduscopic examination were normal. Cardiac examination revealed a grade 2/6 systolic ejection murmur at the right upper sternal border. Abdominal examination was remarkable for a systolic-diastolic bruit present over the right midabdomen without palpable masses. No evidence of pitting edema was observed, and findings on lung examination were normal.
Initial work-up included the following (reference ranges shown parenthetically): hemoglobin, 14.1 g/dL (12.0-15.5 g/dL); creatinine, 0.8 mg/dL (0.7-1.2 mg/dL); sodium, 139 mEq/L (135-145 mEq/L); potassium, 4.2 mmol/L (3.6-4.8 mmol/L); bicarbonate, 29 mEq/L (22-29 mEq/L), and calcium, 9.5 mg/dL (8.9-10.1 mg/dL). Findings on electrocardiography were normal.
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