A 3-year-old with hypertension

by | Feb 20, 2025 | biology

 

You see a 3-year-old with hypertension (documented on three different visits) in your primary care clinic.

Describe the workup, differential diagnoses, assessment, and management.
How would your plan of care be different if the child were 10 years old?
What risk factor counseling and advice would you include?

 

 

Sample solution

Dante Alighieri played a critical role in the literature world through his poem Divine Comedy that was written in the 14th century. The poem contains Inferno, Purgatorio, and Paradiso. The Inferno is a description of the nine circles of torment that are found on the earth. It depicts the realms of the people that have gone against the spiritual values and who, instead, have chosen bestial appetite, violence, or fraud and malice. The nine circles of hell are limbo, lust, gluttony, greed and wrath. Others are heresy, violence, fraud, and treachery. The purpose of this paper is to examine the Dante’s Inferno in the perspective of its portrayal of God’s image and the justification of hell. 

In this epic poem, God is portrayed as a super being guilty of multiple weaknesses including being egotistic, unjust, and hypocritical. Dante, in this poem, depicts God as being more human than divine by challenging God’s omnipotence. Additionally, the manner in which Dante describes Hell is in full contradiction to the morals of God as written in the Bible. When god arranges Hell to flatter Himself, He commits egotism, a sin that is common among human beings (Cheney, 2016). The weakness is depicted in Limbo and on the Gate of Hell where, for instance, God sends those who do not worship Him to Hell. This implies that failure to worship Him is a sin.


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God is also depicted as lacking justice in His actions thus removing the godly image. The injustice is portrayed by the manner in which the sodomites and opportunists are treated. The opportunists are subjected to banner chasing in their lives after death followed by being stung by insects and maggots. They are known to having done neither good nor bad during their lifetimes and, therefore, justice could have demanded that they be granted a neutral punishment having lived a neutral life. The sodomites are also punished unfairly by God when Brunetto Lattini is condemned to hell despite being a good leader (Babor, T. F., McGovern, T., & Robaina, K. (2017). While he commited sodomy, God chooses to ignore all the other good deeds that Brunetto did.

Finally, God is also portrayed as being hypocritical in His actions, a sin that further diminishes His godliness and makes Him more human. A case in point is when God condemns the sin of egotism and goes ahead to commit it repeatedly. Proverbs 29:23 states that “arrogance will bring your downfall, but if you are humble, you will be respected.” When Slattery condemns Dante’s human state as being weak, doubtful, and limited, he is proving God’s hypocrisy because He is also human (Verdicchio, 2015). The actions of God in Hell as portrayed by Dante are inconsistent with the Biblical literature. Both Dante and God are prone to making mistakes, something common among human beings thus making God more human.

To wrap it up, Dante portrays God is more human since He commits the same sins that humans commit: egotism, hypocrisy, and injustice. Hell is justified as being a destination for victims of the mistakes committed by God. The Hell is presented as being a totally different place as compared to what is written about it in the Bible. As a result, reading through the text gives an image of God who is prone to the very mistakes common to humans thus ripping Him off His lofty status of divine and, instead, making Him a mere human. Whether or not Dante did it intentionally is subject to debate but one thing is clear in the poem: the misconstrued notion of God is revealed to future generations.

 

References

Babor, T. F., McGovern, T., & Robaina, K. (2017). Dante’s inferno: Seven deadly sins in scientific publishing and how to avoid them. Addiction Science: A Guide for the Perplexed, 267.

Cheney, L. D. G. (2016). Illustrations for Dante’s Inferno: A Comparative Study of Sandro Botticelli, Giovanni Stradano, and Federico Zuccaro. Cultural and Religious Studies, 4(8), 487.

Verdicchio, M. (2015). Irony and Desire in Dante’s” Inferno” 27. Italica, 285-297.

Seeing a 3-year-old with documented hypertension is concerning and requires a thorough evaluation. Hypertension in young children is often secondary to an underlying condition, unlike in adults where primary hypertension is more common.

3-Year-Old with Hypertension:

Workup:

A comprehensive workup is essential to identify the cause of the hypertension. This includes:

  • Detailed History: Prenatal history (e.g., maternal hypertension, preeclampsia), birth history (e.g., prematurity, low birth weight), family history of hypertension or kidney disease, history of recurrent UTIs, sleep apnea, medications (including over-the-counter and herbal supplements), and dietary habits (e.g., high salt intake).

Seeing a 3-year-old with documented hypertension is concerning and requires a thorough evaluation. Hypertension in young children is often secondary to an underlying condition, unlike in adults where primary hypertension is more common.

3-Year-Old with Hypertension:

Workup:

A comprehensive workup is essential to identify the cause of the hypertension. This includes:

  • Detailed History: Prenatal history (e.g., maternal hypertension, preeclampsia), birth history (e.g., prematurity, low birth weight), family history of hypertension or kidney disease, history of recurrent UTIs, sleep apnea, medications (including over-the-counter and herbal supplements), and dietary habits (e.g., high salt intake).
  • Physical Examination: Accurate blood pressure measurement using appropriately sized cuff, assessment of growth (height, weight, head circumference), careful examination of the heart, abdomen (for kidney enlargement or masses), and neurological system. Look for any dysmorphic features.
  • Laboratory Tests:
    • Urinalysis and urine culture: To assess for kidney disease and infection.
    • Basic metabolic panel (BMP) and complete blood count (CBC): To evaluate kidney function and electrolyte balance.
    • Renal function tests (BUN, creatinine, eGFR): To assess kidney function.
    • Lipid profile: To assess for hyperlipidemia, a risk factor for cardiovascular disease.
    • Renin and aldosterone levels: To investigate potential causes of secondary hypertension.
  • Imaging Studies:
    • Renal ultrasound: To evaluate kidney structure and identify any abnormalities.
    • Echocardiogram: To assess heart structure and function.
    • If indicated, consider a sleep study to evaluate for sleep apnea.
  • 24-hour ambulatory blood pressure monitoring (ABPM): This is important to confirm the diagnosis of hypertension and assess blood pressure variability.

Differential Diagnoses:

  • Renovascular Hypertension: Renal artery stenosis, fibromuscular dysplasia.
  • Renal Parenchymal Disease: Chronic kidney disease, glomerulonephritis, polycystic kidney disease, reflux nephropathy.
  • Coarctation of the Aorta: Narrowing of the aorta.
  • Endocrine Disorders: Hyperaldosteronism, Cushing’s syndrome, pheochromocytoma.
  • Obesity: Increasingly common in young children.
  • Medications: Certain medications (e.g., steroids, decongestants) can raise blood pressure.
  • Sleep Apnea: Obstructive sleep apnea can contribute to hypertension.
  • Essential Hypertension: Less common in this age group, but possible if no secondary cause is found.

Assessment:

The assessment involves correlating the history, physical exam findings, and laboratory/imaging results to determine the most likely cause of the hypertension.

Management:

  • Treat Underlying Cause: The primary focus is to address the underlying condition causing the hypertension. For example, if renal artery stenosis is diagnosed, intervention (angioplasty or surgery) may be required. If the cause is medication-related, the medication should be stopped.
  • Lifestyle Modifications:
    • Healthy diet: Low in sodium, rich in fruits, vegetables, and whole grains.
    • Regular physical activity: Age-appropriate exercise.
    • Weight management: If overweight or obese.
  • Medications: If lifestyle modifications are insufficient or if the hypertension is severe, antihypertensive medication may be necessary. The choice of medication will depend on the underlying cause and the child’s specific circumstances. Commonly used medications include ACE inhibitors, ARBs, beta-blockers, and calcium channel blockers. A pediatric cardiologist or nephrologist should ideally be involved in the management.

10-Year-Old with Hypertension:

The approach to a 10-year-old with hypertension is similar in terms of workup and considering secondary causes, but primary (essential) hypertension becomes more likely in this age group. The differential diagnosis would still include the conditions listed above, but the likelihood of each would shift. For example, renal artery stenosis is less common in this age group.

Key Differences in a 10-year-old:

  • Increased likelihood of essential hypertension: While still less common than in adults, essential hypertension becomes more probable.
  • Focus on lifestyle factors: Diet, exercise, and weight management become even more critical, especially given the rising rates of childhood obesity.
  • Psychosocial factors: Consider the impact of stress and other psychosocial factors on blood pressure.
  • Medication management: The choice of medication and dosing may differ slightly compared to a younger child.

Risk Factor Counseling and Advice (for both age groups):

  • Diet: Emphasize a low-sodium diet, rich in fruits, vegetables, and whole grains. Limit processed foods, sugary drinks, and saturated fats. Involve the family in dietary education.
  • Physical Activity: Encourage regular physical activity (at least 60 minutes most days of the week). Make it fun and age-appropriate.
  • Weight Management: If overweight or obese, develop a weight management plan that includes healthy eating and exercise. Focus on lifestyle changes rather than restrictive dieting.
  • Avoid Tobacco Exposure: Counsel against tobacco use and secondhand smoke exposure.
  • Stress Management: Teach stress-coping techniques, such as deep breathing or mindfulness exercises.
  • Regular Follow-up: Schedule regular blood pressure checks and follow-up appointments to monitor the effectiveness of treatment and adjust the plan as needed.
  • Family Involvement: Engage the family in the child’s care. They play a crucial role in supporting lifestyle changes and medication adherence.

It is crucial to emphasize that hypertension in children, especially at a young age, should be thoroughly investigated to identify and treat any underlying causes. Prompt diagnosis and management can help prevent long-term cardiovascular complications.

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