A 42-year-old man comes to the office due to a painless lump under the skin on his right upper back, which he first noticed 3 months ago. He is incidentally noted to have a blood pressure of 180/110 mm Hg. He has no symptoms. The patient has no history of hypertension or other medical conditions and has not seen a physician since high school. He takes no medications, does not use tobacco, and consumes 1 or 2 alcoholic beverages on weekends. Family history is notable for hypertension in his mother and end-stage renal disease in a maternal uncle. The patient exercised regularly until recently, when he started work as a supervisor at a warehouse. He eats fast food at least 3 days a week. Repeat blood pressure measurements after 15 minutes of rest are 180/105 mm Hg on the right arm and 185/110 mm Hg on the left. Temperature is 36.7 C (98.1 F), pulse is 68/min, and respirations are 12/min. BMI is 26.2 kg/m². Cardiac examination reveals a diffuse and sustained apical impulse with normal heart sounds and no murmurs or gallops. There is a 3-cm, soft, mobile, nontender, subcutaneous mass consistent with a lipoma in the right scapular region. The remainder of the examination, including funduscopy, is normal. Blood cell counts, serum electrolytes, serum creatinine, blood glucose, and urinalysis are within normal limits. The ECG is shown in the exhibit. In addition to providing reassurance regarding the patient's skin lesion, which of the following is the most appropriate next step in management?

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Explanation: 11ec2b69_be5f_4da1_8f63_4dda30a1ff2d_MD0005_00 This patient has newly diagnosed hypertension presenting with a significant elevation in blood pressure (BP) and ECG signs of left ventricular hypertrophy. He has stage 2 hypertension, defined as systolic BP ?140 mm Hg and/or diastolic BP ?90 mm Hg. hypertension Patients with stage 1 hypertension (ie, systolic BP 130-139 mm Hg and/or diastolic BP 80-89) and otherwise low risk for cardiovascular disease may be initially treated with nonpharmacologic therapy. However, patients with stage 2 hypertension are unlikely to achieve adequate BP control without an antihypertensive medication (Choice D). In addition, those whose BP is ?20/10 mm Hg above goal, as in this patient, usually require >1 drug and should usually start with a 2-drug antihypertensive regimen. Close follow-up in the initial period is appropriate to monitor for adverse effects (eg, orthostatic hypotension) of combination antihypertensive therapy. (Choices B and C) Evaluation for secondary causes of hypertension is advised for patients who have resistant hypertension (ie, persistent hypertension despite an appropriate 3-drug regimen), have an abrupt onset of hypertension, or develop hypertension at an unusual age (eg, age <30). A directed secondary hypertension evaluation is also appropriate for patients with specific abnormal findings on initial evaluation (eg, hypokalemia, hematuria, abdominal bruit). However, this patient has no unusual findings that would warrant evaluation for secondary causes of hypertension. secondary causes of hypertension Educational objective: Patients with hypertension whose baseline blood pressure is ?20/10 mm Hg above goal should be initially treated with a 2-drug antihypertensive regimen. References: 2017 ACC/AHA blood pressure treatment guideline recommendations and cardiovascular risk. (http://www.ncbi.nlm.nih.gov/pubmed/30189994)

A 42-Year-Old Man Comes to the Office Due to a Painless