A 32-year-old man comes to the office for follow-up of elevated blood pressure. A week ago, he was seen in the emergency department for nasal bleeding and found to be hypertensive. The patient has no significant medical history. Both parents are alive; his father was diagnosed with coronary artery disease at age 55, and his mother has hypertension and diabetes. Blood pressure is 150/95 mm Hg, and repeat blood pressure measurements demonstrate similar readings. Pulse is 96/min and regular. BMI is 27 kg/m². On examination, no heart murmurs are present. There is no thyromegaly or lymph node enlargement. A fine hand tremor is present. No skin rashes are noted. Laboratory results show a serum TSH of 1.2 µU/mL, normal serum electrolytes, and creatinine of 0.7 mg/dL. Which of the following is the best next step in evaluating this patient?

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11ec25c8_d367_93a5_bc81_49e76761f0a9_MD0003_00 This young patient has new-onset hypertension that, in combination with epistaxis, tremor, and borderline tachycardia, suggests secondary hypertension due to cocaine intoxication. Cocaine is a potent stimulant that causes a sensation of euphoria and increased alertness. However, the sympathomimetic effects of cocaine cause hypertension and tachycardia in a dose-dependent fashion. Other illicit drugs associated with hypertension include other stimulants (eg, amphetamines, 3,4-methylenedioxymethamphetamine [MDMA or Ecstasy]), phencyclidine (PCP), and marijuana. Cocaine is also a prominent cause of epistaxis when administered intranasally (although epistaxis is sometimes attributed to uncontrolled hypertension of any cause, the pathophysiologic link is not strong). Although most patients with elevated blood pressure have primary (idiopathic) hypertension, further diagnostic evaluation is indicated for patients with signs and symptoms of diseases associated with secondary hypertension. Suggestive features include an early age of onset (ie, age <30 in the absence of family history), severe or malignant hypertension, resistant hypertension despite an appropriate 3-drug treatment regimen, and a sudden rise in blood pressure in a patient with previously well-controlled hypertension. In light of this patient's clinical presentation, a urine drug screen should be obtained to evaluate for illicit drug use. secondary hypertension (Choice A) Renal artery stenosis is most common in older adults with widespread atherosclerotic disease and young women with fibromuscular dysplasia. It typically presents with severe hypertension (≥180 systolic or ≥120 diastolic), heart failure, recurrent flash pulmonary edema, or acute kidney injury after initiation of ACE inhibitors. Duplex ultrasound would show >70% renal artery occlusion. (Choice B) Obstructive sleep apnea (OSA) is a common cause of secondary hypertension but usually occurs in obese individuals. Associated symptoms include loud snoring, nonrestorative sleep, daytime somnolence, and morning headaches. The diagnosis can be confirmed by in-laboratory polysomnography, which helps determine OSA severity and management. (Choice C) Pheochromocytoma (eg, catecholamine-secreting adrenal tumor) is a rare disorder that typically manifests with intermittent severe hypertension associated with paroxysms of diaphoresis, headache, and tachycardia. Chronic, mild hypertension is less typical. Plasma or 24-hour urine metanephrine or catecholamine level measurements are used for diagnosis. (Choice D) Primary aldosteronism is characterized by hypertension associated with mild hypernatremia, hypokalemia, and metabolic alkalosis (eg, muscle weakness, paresthesias). Tremor, tachycardia, and epistaxis are more suggestive of cocaine intoxication. Educational objective: Onset of hypertension at a young age (ie, age <30) should raise suspicion for a secondary cause. In addition to hypertension, features suggesting intranasal cocaine use include epistaxis and tremor. A urine drug screen should be considered in a young patient with unexplained hypertension. References: Drug-induced hypertension: an unappreciated cause of secondary hypertension. (http://www.ncbi.nlm.nih.gov/pubmed/22195528)

A 32-Year-Old Man Comes to the Office for Follow-Up of Elevated