Hypertension Review OSCE - Secondary Hypertension Workup

Case Overview

• Age/Sex: 19-year-old male
• Occupation: University student, semi-professional rugby player
• Setting: Primary care clinic appointment requested by patient for follow-up of high blood pressure recorded at team pre-season check
• Chief complaint: "Just here for a blood pressure check"

Patient Script

Who I Am

I'm 19, a university student and play rugby for my club — pretty fit and active most days.

What Brings Me In

My coach said my blood pressure was high at the team physical a few weeks ago, so I thought I should get it checked properly.

My Story

About 3 weeks ago at the team pre-season physical they took my blood pressure and said it was high. Since then I've come in once to recheck it and it was still up, so I was asked to make this appointment. I feel generally well — I train most days and I can still run and lift like normal. Over the last 2 months I've had occasional headaches, usually at the back of my head after intense training or after matches; they come and go and last a few hours. I sometimes get a little lightheaded if I stand up quickly, but no fainting. I have noticed occasional cramping in my calves after long runs, but I assume that's from training harder than usual. I haven't had chest pain or trouble breathing during exercise.

I hadn't planned to come in for anything specific — I wasn't feeling sick — just concerned because the team doc said my blood pressure was raised. I don't take any regular medicine.

My Medical Background

• Past medical history: none of note; childhood illnesses only
• Medications: occasional ibuprofen for muscle soreness; uses creatine and protein shake supplements
• Allergies: none
• Social: lives with teammates; denies tobacco; drinks alcohol socially (2-3 beers on weekends); denies recreational drugs; denies steroid use (I know some guys use them but I don’t)
• Sexual: sexually active, condoms most of the time
• Family history: father alive, early 40s, "healthy"; mother well; a maternal uncle died suddenly in his 40s (I don't know details)

What I Think & Worry About

• I worry this might be something that will stop me playing rugby.
• I hope you can tell me whether it’s serious and what I should do about it.
• I’m worried about whether this is something I caused by what I take, or if it’s something congenital.

If You Ask Me About Other Symptoms...

• Headaches: "Yes, on and off for about 2 months — usually after heavy training or sometimes in the evening."
• Palpitations: "Occasional racing feeling during stressful games, but nothing severe."
• Sweating: "Sometimes sweaty after a game, but I sweat a lot normally when I train."
• Vision: "No blurring or visual loss."
• Urine: "No blood in urine, no change in frequency except I drink a lot when I train."
• Breathlessness: "No, I can complete my training sessions; I get tired like anyone else."
• Drug use: "I don’t use steroids or recreational drugs. I do take creatine and use a decongestant for colds sometimes."
• Sleep: "I sleep okay, don’t snore much according to my roommate."

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Clinical Summary

Examination

• General: well-appearing, athletic male, BMI ~22 kg/m^2
• Vitals: Temperature 36.7°C, HR 78 bpm, Respiratory rate 14/min
• Blood pressure: Right arm 162/100 mmHg, Left arm 160/98 mmHg (sitting)
• Lower limb blood pressure: Right leg 120/78 mmHg, Left leg 118/76 mmHg (measured supine)
• Pulses: radial pulses normal; femoral pulses reduced in volume compared with brachial pulses; noticeable radio–femoral delay
• Cardiac exam: systolic ejection murmur best heard interscapularly (grade II/VI); no S3 or S4
• Lungs: clear to auscultation bilaterally
• Abdomen: soft, no palpable masses; no abdominal bruit on light auscultation (note: depending on examiner technique, a bruit may be subtle)
• Extremities: no peripheral oedema; calves show well-developed musculature; no focal neurological deficits

Investigations

• ECG: Sinus rhythm, rate 78 bpm, evidence of left ventricular hypertrophy (Sokolow–Lyon criteria borderline)
• Urinalysis: no hematuria, no protein
• Serum electrolytes: Na 140 mmol/L, K 4.2 mmol/L (normal) (suggests low likelihood of primary hyperaldosteronism)
• Creatinine: 82 µmol/L (eGFR >90 mL/min/1.73 m2)
• 24-hour urinary metanephrines: within normal range (makes pheochromocytoma unlikely)
• Transthoracic echocardiogram: left ventricular hypertrophy; bicuspid aortic valve with trivial regurgitation
• Renal Doppler ultrasound: renal artery flow velocities within normal limits (no clear renal artery stenosis)
• If performed for confirmation: CT angiography of the aorta: focal narrowing of the proximal descending thoracic aorta distal to the left subclavian artery consistent with coarctation of the aorta (measurement confirms clinically significant gradient)

Diagnosis

Primary diagnosis:

• Coarctation of the aorta presenting as secondary hypertension in a young athletic male — supported by: significant upper limb hypertension with lower limb systolic pressures ~40 mmHg lower, radio–femoral delay, interscapular systolic murmur, echocardiographic finding of bicuspid aortic valve and LVH, and CT angiographic evidence of focal aortic narrowing.

Differential diagnoses (with reasoning):

• Renal artery stenosis (fibromuscular dysplasia or other): considered because of young age and secondary hypertension, but renal Doppler was not suggestive and renal function normal (less likely).
• Pheochromocytoma: considered due to episodic headaches and palpitations, but 24-hour urinary metanephrines were normal (less likely).
• Primary (essential) hypertension: possible but unusual at age 19 without risk factors; presence of vascular findings and congenital valve abnormality point strongly to secondary cause.
• Medication/supplement-induced hypertension (e.g., NSAIDs, decongestants, anabolic steroids): possible contributors — patient reports occasional ibuprofen and decongestant use and creatine/protein supplements but denies steroids; these are unlikely to fully explain the marked arm–leg gradient and physical findings.

Management

• Immediate:
  • Begin blood pressure control while arranging definitive care — consider initiating an oral antihypertensive suitable for young patients (e.g., beta-blocker such as labetalol or other agent per local guidelines) targeting safe reduction rather than abrupt drop in BP.
  • Counsel patient to avoid heavy isometric exertion and competitive play until cardiovascular team review and BP control are achieved.
• Investigation/Referral:
  • Urgent referral to cardiology and cardiothoracic/vascular surgery for further assessment.
  • Obtain CT angiography or MR angiography of the thoracic aorta to define anatomy and gradient (if not already done).
  • Full cardiac workup: formal echocardiography (already performed) and cardiology review for associated lesions (bicuspid aortic valve surveillance).
• Definitive treatment options (to be decided by specialist):
  • Endovascular repair (balloon angioplasty with stent) or surgical repair depending on anatomy, patient age and centre expertise.
• Long-term:
  • Lifelong surveillance for recoarctation and complications; follow-up BP monitoring, echocardiographic assessment of valve function, and cardiovascular risk reduction.
  • Educate regarding signs of end-organ damage and when to seek urgent care.

Key Learning Points

• In young patients with hypertension, always consider secondary causes; measure blood pressure in both arms and compare to leg pressures when feasible.
• Physical signs such as radio–femoral delay, an interscapular systolic murmur, and an associated bicuspid aortic valve suggest coarctation of the aorta and warrant imaging (CT/MR angiography) and specialist referral.
• Don’t be misled by common distractors (supplements, occasional decongestant/NSAID use, intermittent headaches); targeted history, focused exam and appropriate investigations are essential to identify congenital vascular causes of secondary hypertension.