Essential hypertension- This is the most likely diagnosis for this patient. The reason that this is chosen as the most likely diagnosis is due to the high prevalence of hypertension which is found in 34% of the U.S. population and occurs in one out of three Americans (Dunphy et al. , 2019). The patient has two readings of systolic blood pressure on two separate dates of greater than 140 placing her in the category of stage 2 hypertension. There is no single identifiable cause of elevated blood pressure in 95% of people with this condition which is then diagnosed as essential or primary hypertension (Dunphy et al.,2019). Less than 5 % of people with elevated blood pressure are found to have a specific cause such as medication induced, renal, or endocrine problems ( Dunphy et al.,2019). Therefore, it is most likely that this patient has elevated blood pressure due to essential hypertension. This diagnosis was solidified by asking follow up questions inquiring about any medications that could be contributing to high blood pressure which the patient reported a negative response to. The patient has proteinuria, signs of hypertensive retinopathy on fundoscopic exam, and renal insufficiency which are common manifestations of hypertension (Dunphy et al.,2019). The fact that she reports lack of exercise and excess sodium in her diet put her at risk for essential hypertension (Dunphy et al.,2019).
White Coat Hypertension- White coat hypertension is found in 13% of patients. Patients will experience higher readings in the primary care office setting than at home readings. According to one review 30%-40% of patients who were diagnosed with hypertension in the office setting were normotensive by ambulatory blood pressure readings (Dunphy et al.,2019). In order to rule in or out this I asked the patient about home readings. The patient reports at home her readings have been 130’s/ 80s which although lower than found in the office is still classified as hypertension. I would want to rule out white coat hypertension further by ordering a 24-hour ambulatory blood pressure monitor. Depending on the resources in my office I could refer the patient to a remote patient monitoring blood pressure program to assess further home readings. At the very least I would like to at least have a log of the patient monitoring her blood pressure at home in the morning and in the evening for at least two weeks.
Chronic venous disease– The patient has lower extremity edema which is a common manifestation of chronic venous disease. This condition may result from hypertension and is present in up to 50% of people. Standing for long periods of time can contribute to development of the condition and the patient is a teacher so she may be standing for long periods of time during the day in her classroom. This condition is more prevalent in women which fits the picture of our patient. Confirming the diagnosis would involve asking about typical symptoms such as leg pain or heaviness. Definitive diagnosis would be made by Venous duplex ultrasound however, I would first discuss with the patient eliminating salt in the diet and elevating the legs to see if this helps alleviate the problem first (Kabnick & Scovell, 2023).
Glomerular disease- This patient has renal insufficiency demonstrated by a creatinine of 2.0 mg/dl. The patient also has both proteinuria and edema which may be seen due to renal sodium retention caused by glomerular disease. Providers should be suspicious for glomerular disease when there is acute onset of hypertension in a previously normotensive patient or worsening of hypertension in someone who previously had controlled hypertension. The first thing to do would be to rule out chronic kidney disease and proteinuria as a result of diabetes by ordering a fasting glucose. A urinalysis could be ordered to evaluate for the presence of hematuria which can be present in some forms of kidney disease ( Radhakrishnan, 2023).
Heart failure– This diagnosis occurs when cardiac output does not meet the metabolic demands of the body. Heart failure can be caused by long standing hypertension and one of the first presenting symptoms can be lower extremity edema. Evidence against this would be that on exam lungs were clear bilaterally with good aeration. The diagnosis could be ruled out by ordering a BNP, ECG, ECHO, and chest xray (Dunphy et al.,2019).
Type II diabetes- Is an endocrine disorder caused by impaired metabolism of carbohydrates, fat, and protein leading to hyperglycemia which results in organ damage including that of the kidneys and eyes if left uncontrolled. In setting of renal insufficiency and proteinuria type II diabetes should
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