A 46-year-old man comes to the office for follow-up due to a blood pressure reading of 150/95 mm Hg during a preemployment examination. He has had no symptoms, and his medical history is unremarkable. The patient is an ex-smoker with a 10-pack-year history; he does not use alcohol or illicit drugs. He has a family history of hypertension, and his father died of a stroke at age 68. Blood pressure is 145/90 mm Hg (repeat: 144/92 mm Hg), and pulse is 75/min and regular. BMI is 29 kg/m². Physical examination is unremarkable. This patient should be screened for which of the following conditions?

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11ec25c8_d248_678b_bc81_3174102d76bd_MD0003_00 This patient has a new diagnosis of hypertension, defined as a sustained blood pressure ≥130 mm Hg systolic or ≥80 diastolic (some guidelines recommend a blood pressure ≥140/90 as the threshold for diagnosis). The initial evaluation of hypertension is directed to identify complications of hypertension or comorbid conditions (eg, chronic kidney disease) that might influence management decisions. Assessment in most cases should include a serum chemistry panel (including electrolytes and creatinine), hemoglobin/hematocrit, and urinalysis. Some experts also advise measuring serum TSH because subclinical thyroid disorders increase the risk for hypertension; testing for other secondary causes is not routinely needed. 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 generally recommended (especially in men age ≥35 and women age ≥45), and patients (especially overweight or obese individuals, such as this patient) should be screened for diabetes mellitus with either fasting blood glucose, which can be obtained as part of a standard serum chemistry panel, or hemoglobin A1c. Also, an ECG should be obtained to screen for signs of left ventricular hypertrophy or prior myocardial infarct. (Choice A) Screening for abdominal aortic aneurysm with a one-time abdominal ultrasound is recommended for men age 65-75 who have ever smoked. Screening may also benefit men age 65-75 who have not smoked but have other significant risk factors (eg, first-degree family history of abdominal aortic aneurysm rupture). Screening in younger men and in women has little benefit and is not recommended. (Choice B) Screening for intracranial aneurysms is recommended by some experts for patients with autosomal dominant polycystic kidney disease or with a family history of aneurysms in ≥2 first-degree relatives. Screening in the general population is not recommended. (Choice D) Indications for testing for pheochromocytoma include resistant hypertension (ie, sustained hypertension despite an appropriate 3-drug treatment regimen); episodic, severe hypertension, especially when associated with adrenergic symptoms (eg, diaphoresis, tachycardia); adrenal incidentaloma noted on imaging; and hypertension in a patient with a family history of pheochromocytoma or multiple endocrine neoplasia. Pheochromocytoma is a rare condition, and screening is otherwise not necessary. (Choice E) Renal artery stenosis should be suspected in patients with resistant hypertension, recurrent flash pulmonary edema, abdominal bruit, or acute kidney injury after initiation of an ACE inhibitor. It is most common in older adults with widespread atherosclerotic disease and young women with fibromuscular dysplasia but would be unlikely in this younger man with mild hypertension. 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. References: Hypertension: the role of biochemistry in the diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/28007614)

A 46-Year-Old Man Comes to the Office for Follow-Up Due