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. Which of the following additional tests is most appropriate for this patient?

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Explanation: 11ec2b69_be60_3802_8f63_e39b98e6252b_MD0005_00 This patient has a new diagnosis of hypertension. Initial evaluation is oriented to the following objectives: Detecting end-organ damage that may require more aggressive management Assessing other cardiovascular risk factors Screening for common secondary causes of hypertension (eg, thyroid disorders, hyperaldosteronism) Identifying concurrent conditions and metabolic abnormalities that could influence the choice of antihypertensive therapy As part of initial workup, a fasting lipid profile should be ordered in all hypertensive patients to calculate the risk for cardiovascular events. The target blood pressure is determined, in part, by this risk, with lower targets recommended for those at increased risk. (Choices A and D) Coronary angiography and stress echocardiography are considered for patients with symptoms of coronary heart disease but not asymptomatic patients with hypertension. Resting echocardiography can be considered, especially for those with signs of left ventricular hypertrophy on ECG. (Choice C) Renal ultrasonography is useful for evaluating patients with clinical features suggesting renovascular hypertension, including atrophic kidney, recurrent flash pulmonary edema, abdominal bruit, and initial onset of severe hypertension (ie, >180/110 mm Hg) at age >55 or in the setting of diffuse atherosclerosis. (Choice E) Some illicit drugs (eg, cocaine, methamphetamines) can transiently raise blood pressure; however, this patient has no signs of acute drug intoxication. Moreover, he has evidence of left ventricular hypertrophy, suggesting long-standing hypertension. Educational objective: Patients with hypertension should be evaluated to identify additional cardiovascular risk factors and end-organ damage. Suggested studies include fasting lipid profile and glucose, urinalysis, serum electrolytes and creatinine, and ECG. 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