12yo M with non-verbal autism spectrum disorder and hypertension.  

 
The patient’s blood pressure was first noted to be elevated about 2 years ago and since then has continued to be elevated on multiple occasions, with reported values as high as 149 mmHg systolic and 119 mmHg diastolic in the last 6-9 months. He is followed by nephrology with an unremarkable workup.  After clinic he was referred to get labs for both hypertension and tachycardia on exam. The labs demonstrated slightly elevated Cr from baseline and elevated WBC (31.5) in the absence of fever. He also had a slightly elevated bilirubin (1.2). Caretaker noted that the patient has been afebrile with URI symptoms, but was not eating or drinking. They were instructed to present to the ED for further work up.  

Denies vomiting, diarrhea, syncope, focal neurologic deficits, seizure-like activity, history of UTI, hematuria, edema, change in urine output, heat intolerance, diaphoresis, tremors, weight loss, episodic flushing, snoring, witnessed apneas, or daytime somnolence. No sick contacts. 

FMHx: + HTN (diagnosed in mother during childhood), +HTN in brother (on 2 BP meds)  

Meds: Adderall.  

Vital signs:  

Temp 37.4, HR 160, BP 139/97, RR 16, 97% on RA 

Physical Exam: 

General:  Alert,  small for age, intermittently engaged in exam.    

Skin:  pale, mottled skin on hands  

Eye:  EOMI,  normal conjunctiva,  no jaundice.    

Cardiovascular:  Normal peripheral perfusion, tachycardiac, no murmur, 2-3 second cap refill.   No peripheral edema. 

Respiratory:  Lungs are clear to auscultation, respirations are non-labored, breath sounds are equal.    

Gastrointestinal:  Soft, nontender, non-distended.     

Renal function markers are normal — BUN 12 mg/dL, Cr 0.61 mg/dL. Urinalysis (not a clean sample) is abnormal with 1+ protein, trace leukocyte esterase, 9 WBC/HPF, and 6 RBC/HPF. Calcium, phosphorus, and parathyroid hormone levels are normal at 9.8 mg/dL (normal range 9-10.6), 4.3 mg/dL (normal range 3.2-6.1), and 32.9 pg/mL (normal range 12-85). Thyroid studies are normal at TSH 2.06 uIU/mL (normal range 0.7 – 4.01) and T4 7 mcg/dL (normal range 5.8-11.8). White blood cell count and absolute neutrophil count are elevated at 30.1 K/mcL and 24.68 K/mcL. Hemoglobin and hematocrit are normal at 14 g/dL and 39%. Platelet count is mildly elevated at 370 K/mcL. 
 

EKG: Sinus tachycardia, otherwise normal EKG.  

US RENAL WITH DOPPLER READ:  

1.  Normal ultrasound appearance of the bilateral kidneys and urinary bladder.  

2.  No sonographic evidence of renal artery stenosis.