Hypertension Quiz: Ace Your Exams

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A 60-year-old man comes to the physician office due decreased vision, progressive fatigue and swelling around the ankles for the past 4 weeks. Medical history is significant for myocardial infarction 2 years ago, diabetes mellitus type 2 and hypertension. Current medications include aspirin, captopril, metformin and lovastatin. Temperature is 36.4°C (97.5°F), pulse is 80/min, and blood pressure is 144/90 mmHg.  Physical examination shows 2+ edema around the ankles bilaterally. Fundoscopic examination reveals retinal arteriolar narrowing, arteriovenous nicking, and flame-shaped hemorrhages. Laboratories studies are shown:
 
 
 Laboratory value  Result 
 Hemoglobin  10.5 mg/dL (reference range: 13.5-17.5 mg/dL) 
 Leukocytes  7000/mm3 (reference range: 4,500-11,000/mm3) 
 Platelets   200,000/mm3 (reference range: 150,000-400,000/mm3) 
 Serum 
 Sodium   136 mEq/L (reference range: 136-146 mEq/L) 
 Potassium   5.3 mEq/L (reference range: 3.5-5 mEq/L) 
 Chloride   101 mEq/L (reference range: 95-105 mEq/L) 
 Creatinine   3.9 mg/dL (reference range: 0.6-1.2 mg/dL) 
 Calcium   8.5 mg/dL (reference range: 8.4-10.2 mg/dL) 
 Albumin   3.2 g/dL (reference range: 3.5-5.5 g/dL) 
 BUN  65 mg/dL (reference range: 7-18 mg/dL) 
 HbA1c  5.8% (reference range: ≤6%) 
 Urine  
 Erythrocytes  0/hpf (reference range: 0-3/hpf) 
 Leukocytes  2/hpf (reference range: 0-2/hpf) 
         Protein   3+ (reference range: none)  
 Glucose  1+ (reference range: none)  
 Sediment   None (reference range: none) 
   
Which of the following is likely responsible for this patient’s eye examination findings? 

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