Hypertension in children — branching viva

Stem 1 — Eight-year-old with an elevated blood pressure at a routine check (5 minutes)

An eight-year-old girl has a blood pressure of 118/76 mmHg at her eight-year check, between the 90th and 95th percentile for her age, sex and height. The practice nurse asks you what to do. [1]

Branch A (examiner): How do you classify this reading, and what is the confirmation rule before you label her hypertensive? [1]

Branch B (examiner): What role does ambulatory blood pressure monitoring play here, and how does it distinguish white-coat from masked hypertension? [5] [3]

Branch C (examiner): If her three repeat readings and her ambulatory study are normal, what lifestyle advice still applies, and how often would you re-screen her? [7]

Stem 2 — Six-year-old with stage 2 hypertension and proteinuria (5 minutes)

A six-year-old boy is referred with a blood pressure of 124/84 mmHg, above the 95th percentile plus 12 mmHg for his age. His urinalysis shows protein and blood, and a renal ultrasound shows a small scarred left kidney with a normal, enlarged right kidney. [1]

Branch A (examiner): Why is this child almost certain to have a secondary cause, and what is the most likely underlying diagnosis given the ultrasound? [1] [4]

Branch B (examiner): Outline your first-line investigation panel and the single most important target-organ investigation. What finding on the latter would mandate drug therapy? [1]

Branch C (examiner): Which drug class is first-line here and why, and what must you monitor when you start it? [1] [8]

Stem 3 — Twelve-year-old with hypertensive encephalopathy (5 minutes)

A twelve-year-old boy presents to the emergency department with a two-day history of severe headache and blurred vision. His blood pressure is 170/110 mmHg. He is drowsy and has papilloedema on fundoscopy. [11]

Branch A (examiner): What is the diagnosis, and why must you not lower his blood pressure rapidly to the normal range? [11]

Branch B (examiner): State the controlled-reduction rule and name two intravenous agents you would use. Where would you manage him? [11]

Branch C (examiner): Once his blood pressure is controlled, how do you search for the underlying cause, and what is the likely diagnosis in this age group with this severity? [1] [8]