A 56-year-old man who has had borderline hypertension for 2 to 3 years presents at a regularly scheduled office visit with blood pressure of 149/91 mm Hg.
Medical history
- No other significant medical or psychiatric problems
- Married, with 2 teenaged children
- Employed as an administrator for an insurance company (>50 hrs/wk)
- Drinks 3 to 4 alcoholic beverages/wk
- Does not smoke
- Enjoys fishing and other outdoor activities
- Both parents had hypertension; father also had peripheral vascular disease
Examination
- Patient is in no acute distress
- Approximately 30 pounds over ideal body weight
- Other vital signs are normal
- Normal retinal examination, no carotid bruits, and clear lungs. Cardiac rate and rhythm are regular; no abdominal bruits
- Laboratory studies reveal normal renal function; cholesterol, 184 mg/dL; low-density lipoprotein (LDL) cholesterol, 129 mg/dL; high-density lipoprotein (HDL) cholesterol, 55 mg/dL; triglycerides, 163 mg/dL. Electrocardiogram shows no current or prior evidence of ischemia or left-ventricular strain.
Additional information is required in a number of domains. Blood pressure readings should be repeated to make an accurate diagnosis of hypertension. While the patient may have hypertension, only a single blood pressure reading is elevated. The Joint National Committee on Blood Pressure (JNC 7) specifications1 state that 2 such readings on different days are needed to confirm a diagnosis of hypertension. The symptoms of claudication should be investigated. Physical examination should focus on auscultation for bruits and on the examination of eye grounds to further investigate the possibility of peripheral vascular disease (PVD). In addition, a lipid profile should be drawn. While guidelines are conflicting, consideration should be given to assessing a fasting glucose, potassium, and renal function. Other tests, such as a C-reactive protein, are more controversial.2
The patient opts for drug treatment of his hypertension, and begins taking atenolol 50 mg/d (in addition to aspirin 81 mg/d). He is scheduled to follow-up by phone in 1 week to assure compliance and in 3 months in the office.
FOLLOW-UP CARE
On a return visit to the office 3 months later, the patient reports the recent onset of fatigue.
Q: What is the differential diagnosis of the patient’s symptoms? What additional information might you like to know? A:__________________________________
____________________________________
On further questioning he reports that he initially tolerated the beta-blocker without problem, but more recently has experienced low energy and poor sleep (with early morning awakening); he acknowledges decreases in libido, interest in pleasurable activities (eg, hunting, fishing), and his ability to concentrate. He has gained 5 to 10 pounds in the last month.
Although he denies feeling “sad,” he says his emotions seem “flat.” He denies having thoughts of suicide, increased anxiety, symptoms of hypomania, or psychotic symptoms. He describes a mild increase in stress at work, and he feels that the process of preparing for his son to go to college had been “a big burden.” He says there are no other stressors.
The patient’s alcohol use has not changed significantly, and he reports being compliant with his new medication regimen.
When his father died 6 years earlier, he experienced similar symptoms; at no other time have such symptoms occurred. The patient reports no other new physical symptoms, and his physical examination is essentially unchanged from the exam conducted 3 months earlier. His vital signs are normal, including a blood pressure of 128/84 mm Hg.
Consider the differential diagnosis of the patient’s abnormal mood and neurovegetative symptoms. In the primary care setting, the differential diagnosis of depressed mood is broad (Table 1 ), including medical disorders and a variety of psychiatric syndromes.
Medical conditions to consider include a medication induced side effect, hypothyroidism (a metabolic masquerader of depression), anemia, sleep disorder (eg, sleep apnea), and alcohol abuse. PVD should also be considered—his symptoms may be secondary to poor perfusion of the cerebral cortex.
TABLE 1
Partial differential diagnosis of depressed mood and neurovegetative symptoms
| General medical conditions |
| Endocrine: hypothyroidism, Cushing’s syndrome |
| Hematologic: anemia |
| Nutritional: vitamin B12 deficiency |
| Neurologic: movement disorders (eg, Parkinson’s disease, Huntington’s disease), head trauma, seizure disorders |
| Vascular: peripheral vascular disease, cerebrovascular accident |
| Sleep disorders: sleep apnea, narcolepsy |
| Neoplastic: pancreatic, lung, central nervous system neoplasms |
| Substance abuse disorders |
| Alcohol, benzodiazepine, or barbiturate dependence |
| Cocaine or amphetamine withdrawal |
| Psychiatric disorders |
| Major depressive disorder |
| Dysthymia |
| Adjustment disorder with depressed mood |
| Bipolar disorder |
Q: When are depressive symptoms serious enough to warrant treatment?
What effects might beta-blockers be having on his mood, energy level, and libido?
You call a psychiatrist colleague for an informal consultation.
Psychiatrist’s comments
It is important to distinguish major depression from other, less severe depressive syndromes. In major depression, 5 out of 9 symptoms (including depressed mood or anhedonia) are present most of the day nearly every day for 2 weeks.