156) A 25 year old woman presents to your office with complaints of muscle cramps and weakness. On examination, she is afebrile, heart rate is 88/min and blood pressure is 150/98. Ophthalmoscopic examination shows the following :
Laboratory investigations reveal a Sodium of 144 meq/L, potassium of 3.0meq/L, Chloride 98meq/L , Bicarbonate of 34meq/L and Creatinine of 0.8mg%. Urinary chloride is 45meq/L. The most likely diagnosis that explains this patient’s clinical features :
A) Gitelman’s syndrome
B) Chronic Laxative abuse
C) Diuretic Abuse
D) Primary Hyperaldosteronism
E) Bartter’s syndrome
Archer USMLE Step 3 Blog 
Ans D.
Most patients of bartter and gitelman syndrome have low or low-to-normal blood pressure. They may show signs of volume depletion.
D
ddd
D
Ophthalmoscopy- grade 2 hypertensive retinopathy
Labs- hypokalemic, metabolic alkalosis chloride resistant type( urine chloride >20 mEq/L)
A & E don’t cause hypertensive retinopathy
B causes metabolic acidosis
C causes chloride responsive type of Metab. Alkalosis ( urine chloride is < 10 mEq/L) initially high but low afterwards when it is depleted.
D hypertension, metabolic alkalosis, and chloride resistant type – yes chloride is reabsorped so it should be low but it become high in urine by pressue/ volume diuresis, phenomenon called aldosterone escape. ANSWER – D
Mistake, chronic laxative abuse typically causes metabolic alkalosis
Chronic laxative abuse causes metabolic acidosis or normal anion gap metabolic acidosis but both scenarios are chloride responsive type (urine chloride <10mEq/L) Answer is D, the only option that causes hypertension
I have a simpler way to answer this question. The ophthalmoscopy shows signs of grade II hypertensive retinopathy (AV nipping). By exclusion principle, the only option that causes hypertension is primary hyperaldosteronism (Option D).
My answer is Option D.
D