A 43-year-old woman comes to the office for evaluation of high blood pressure. She exercises regularly and has followed a low-salt diet over the last 2 months. At the patient's previous 2 visits, blood pressure was 154/88 and 150/92 mm Hg. She has no headaches or other symptoms. Medical history is notable for asthma, for which the patient uses a fluticasone inhaler and, very occasionally, as-needed albuterol. She does not smoke or use alcohol and has no known drug allergies. Family history is significant for myocardial infarction in her father at age 65. During this visit, blood pressure is 146/89 mm Hg and pulse is 69/min. BMI is 27 kg/m². Heart and lung examinations are unremarkable. No vascular bruits are heard, and peripheral pulses are 2+ and symmetrical. ECG shows normal sinus rhythm. Complete blood count and chemistry panel are normal. Which of the following additional studies is recommended for this patient?

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Explanation: 11ec25c8_d246_44aa_bc81_13849e8eda78_MD0003_00 The initial evaluation of hypertension is directed to identify complications of hypertension or comorbid conditions that might influence management. Baseline assessment should include: Serum chemistry panel (including electrolytes and creatinine) and hemoglobin/hematocrit. Urinalysis to exclude hematuria and evaluate for proteinuria. ECG to screen for left ventricular hypertrophy or prior myocardial infarct. Some experts advise measuring serum TSH because thyroid disorders are common and increase the risk for hypertension. In addition, patients with hypertension are at increased risk for ischemic heart disease and should be screened for other major atherosclerotic risk factors. A lipid panel is recommended, and patients should be screened for diabetes mellitus with either fasting blood glucose, which may be obtained as part of a standard serum chemistry panel, or hemoglobin A1c. Because primary hypertension is much more common than secondary hypertension, further diagnostic evaluation is indicated only in patients with atypical presentations (eg, onset at age <30), resistant hypertension (requiring >3 medications), or signs and symptoms suggestive of a specific etiology. specific etiology (Choice A) A 24-hour urine cortisol excretion is used to test for Cushing syndrome. However, Cushing syndrome typically presents with characteristic examination findings (eg, central obesity, abdominal striae, facial plethora) not present in this patient. (Choice C) Plasma metanephrines are used to evaluate for pheochromocytoma. However, pheochromocytoma is exceedingly rare and classically presents with severe, paroxysmal hypertension associated with adrenergic symptoms (eg, palpitations, diaphoresis). (Choice D) Measurement of plasma renin activity and aldosterone concentration is used to diagnose primary hyperaldosteronism. Patients typically have severe, resistant hypertension associated with hypokalemia (particularly in those treated with diuretics). Testing is not recommended for patients with uncomplicated hypertension and normal baseline serum potassium. (Choice E) Renal ultrasound is considered for patients with features suggesting renal disease (eg, elevated creatinine, abnormal urinalysis) or renal artery stenosis (eg, resistant hypertension, recurrent flash pulmonary edema, abdominal bruit, acute kidney injury after initiation of an ACE inhibitor). Educational objective: The initial evaluation of hypertension focuses on identifying complications or comorbid conditions that might influence management. Assessment should include a serum chemistry panel, hemoglobin/hematocrit, and urinalysis. In addition, patients should be screened for major atherosclerotic risk factors with a lipid panel and either fasting serum glucose or hemoglobin A1c.

A 43-Year-Old Woman Comes to the Office for Evaluation of High