A 38-year-old man comes to the office for follow-up after his blood pressure was found to be elevated at a health fair. The patient has had no headache, blurry vision, or chest pain. He does not use tobacco, alcohol, or illicit drugs. Temperature is 36.7 C (98.1 F), blood pressure is 148/96 mm Hg in the right arm and 146/94 mm Hg in the left, pulse is 74/min, and respirations are 14/min. BMI is 36 kg/m². Examination shows a regular heart rate and rhythm with no heart murmurs or carotid and abdominal bruits. Peripheral pulses are 2+ without radiofemoral delay. Breath sounds are normal. ECG is normal, and a 48-hour ambulatory blood pressure monitor shows an average pressure of 138/88 mm Hg. Which of the following is the best next step in management of this patient?

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11ec25c8_d21a_a089_bc81_39e60b4c0c53_MD0003_00 This patient has a new diagnosis of hypertension confirmed with office and ambulatory blood pressure measurements. Diagnostic criteria for hypertension vary according to different guidelines, but a blood pressure persistently at ≥130 mm Hg systolic and/or ≥80 mm Hg diastolic is generally considered hypertensive. new diagnosis of hypertension The initial evaluation of hypertension is directed to rule out common secondary causes, end-organ complications, and additional risk factors that may influence management. Hypertension is a major risk factor for chronic kidney disease, and conversely, kidney disease can cause secondary hypertension. Therefore, patients' renal function, including serum creatinine, electrolytes, and urinalysis, should be assessed at the time of diagnosis. Because the risk of cardiovascular complications is greater in patients with comorbid hyperlipidemia or diabetes mellitus, a blood glucose (or hemoglobin A1c) and lipid panel are indicated. Also, many experts recommend a serum TSH for all patients with hypertension because thyroid disorders are common and often present with asymptomatic hypertension. (Choices A and B) Screening for infrequent secondary causes is needed only for patients with an atypical presentation (eg, onset at age <30), resistant hypertension (ie, uncontrolled despite an appropriate 3-drug regimen), or specific signs of a secondary hypertensive disorder. Examples of signs of a secondary hypertension include hypokalemia, suggesting hyperaldosteronism and confirmed with a plasma renin/aldosterone ratio, or atypical body fat distribution, suggesting Cushing syndrome and confirmed with 24-hour urinary free cortisol. (Choice D) ECG is recommended in the initial evaluation of hypertension to rule out common cardiovascular complications (eg, left ventricular hypertrophy, myocardial infarction). However, in the absence of abnormal examination (eg, murmur) or ECG findings, more advanced testing (eg, echocardiography) is not generally necessary. Educational objective: Hypertension is a major risk factor for chronic kidney disease and conversely, kidney disease can cause secondary hypertension. Therefore, patients with hypertension should have their renal function (including serum creatinine, electrolytes, and urinalysis) assessed at the time of diagnosis. References: 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/29146533)

A 38-Year-Old Man Comes to the Office for Follow-Up After