Hypertension in children — formative SAQs

SAQ 1 — Six-year-old with stage 2 hypertension at a school check (10 marks, 15 minutes)

A six-year-old boy has a blood pressure of 124/84 mmHg recorded at a school entry health check, well above the 95th percentile for his age, sex and height. On repeat measurement in your clinic two weeks later it is 122/82 mmHg. He is asymptomatic, on the 50th centile for weight, and has no family history of note. His urinalysis shows 2+ protein and 1+ blood, and his creatinine is at the upper limit of normal. A renal ultrasound shows a small left kidney with cortical thinning and an enlarged, normal right kidney. ^[1]

a) What is the correct diagnostic category of his blood pressure, and why is a single elevated reading not enough to label him hypertensive? Outline how you confirm the diagnosis. (3 marks) ^[1]

b) Given his age, his blood pressure category and his urinalysis, what is the most likely cause of his hypertension, and what does the ultrasound finding of a small scarred left kidney suggest about the underlying renal diagnosis? Name two further investigations you would request to define the cause and the target-organ status. (4 marks) ^{[1] [4]}

c) Outline your management plan, including the first-line drug class you would choose and the blood-pressure target you would aim for, and explain why an ACE inhibitor is particularly appropriate here. (3 marks) ^{[1] [8]}