A 42-year-old man comes to the office after his blood pressure was found to be 146/92 mm Hg at a health fair. The patient has had no unusual headaches, blurry vision, polyuria, chest pain, or shortness of breath. He has no significant prior medical conditions and takes no medications. HIV testing 3 years ago was negative. The patient's father was diagnosed with colon cancer at age 65, and his brother underwent a thyroidectomy for differentiated papillary thyroid cancer at age 34. The patient has a current 15-pack-year smoking history and does not drink alcohol or use illicit drugs. Blood pressure is 140/90 mm Hg, and pulse is 68/min and regular. BMI is 27 kg/m². Repeat blood pressure measurement after 5 minutes is 140/92 mm Hg. Physical examination is unremarkable. Nonfasting laboratory results are as follows: Urine microalbumin/creatinine ratio, TSH, and ECG are normal. A fasting lipid profile has been ordered. Which of the following additional tests is recommended at this time?

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11ec193a_97d2_6c1c_853d_b180982ed649_MD0002_00 The prevalence of type 2 diabetes mellitus is increased in patients with hypertension, at least in part due to shared risk factors (eg, obesity, sedentary lifestyle). Furthermore, hypertensive patients who also have diabetes are at elevated risk for cardiovascular complications (eg, myocardial infarction, stroke). For these reasons, screening for diabetes is recommended for patients with a new diagnosis of hypertension. Identifying comorbid diabetes is also important because it may influence the choice of antihypertensive therapy (eg, ACE inhibitor). Screening tests for diabetes include fasting blood glucose, hemoglobin A1c, and a 2-hour oral glucose tolerance test (used primarily in pregnant women). Nonfasting glucose levels can be helpful, especially when very high (≥200 mg/dL), but are less specific, and mild elevations (as in this patient) should be confirmed with a fasting glucose or hemoglobin A1c. Screening is also appropriate for patients who are overweight or obese and those who have a sedentary lifestyle, first-degree family history of diabetes, or history of gestational diabetes. (Choice B) Screening for lung cancer with an annual low-dose CT scan of the chest is indicated for patients age 50-80 who have a ≥20-pack-year smoking history and who currently smoke or quit within the last 15 years. In light of this patient's younger age and <20-pack-year history, screening is not recommended. (Choices C and D) Testing for primary hyperaldosteronism with a plasma aldosterone/renin activity ratio is appropriate for patients with resistant hypertension (ie, uncontrolled despite an appropriate multidrug regimen) or hypertension with significant hypokalemia. Screening for pheochromocytoma with plasma fractionated metanephrines is appropriate for patients with severe, labile, or resistant hypertension. These tests are not needed for routine evaluation of uncomplicated hypertension. (Choice E) Screening for thyroid malignancy with ultrasound is indicated for patients at high risk for thyroid cancer (eg, multiple endocrine neoplasia type 2, childhood neck irradiation). This patient's brother had papillary thyroid cancer, which is usually sporadic and does not warrant screening of family members. Educational objective: The prevalence of type 2 diabetes mellitus is increased in patients with hypertension, and patients with both hypertension and diabetes are at increased risk for cardiovascular complications. Patients with hypertension should be screened for diabetes with a fasting glucose level, hemoglobin A1c, or oral glucose tolerance test. __________ References: Diabetes mellitus: screening and diagnosis. (http://www.ncbi.nlm.nih.gov/pubmed/26926406)

A 42-Year-Old Man Comes to the Office After His Blood