From the Guidelines
The most appropriate next step for this 65-year-old man with significantly elevated blood pressure (192/105 mmHg) is to order a complete blood count, urinalysis, basic metabolic profile, lipid level, and ECG (option A). This patient presents with severe hypertension without symptoms, which requires proper evaluation before determining treatment. These initial tests are essential to assess for end-organ damage, identify secondary causes of hypertension, evaluate cardiovascular risk factors, and establish baseline values before initiating antihypertensive therapy. The basic metabolic profile will help evaluate kidney function and electrolyte balance, while urinalysis can detect proteinuria or hematuria suggesting renal involvement. The lipid panel assesses cardiovascular risk, and an ECG can identify left ventricular hypertrophy or other cardiac abnormalities related to hypertension. According to the 2017 American College of Cardiology/American Heart Association hypertension guideline 1, screening for a secondary cause of hypertension is recommended in certain circumstances, and these initial tests can help identify such causes. Additionally, the guideline recommends lifestyle changes and possibly antihypertensive medication for patients with stage 1 or 2 hypertension, but only after assessing the patient's overall cardiovascular risk 1. Since the patient is hemodynamically stable without symptoms of hypertensive emergency, immediate emergency department transfer is unnecessary. More specialized testing like echocardiography, carotid ultrasonography, or stress testing would be premature before obtaining these basic diagnostic studies. After this initial workup, appropriate antihypertensive therapy can be initiated based on findings. It's also important to consider the patient's age and potential for secondary causes of hypertension, as well as the need for a comprehensive approach to managing cardiovascular risk, as outlined in the American Heart Association guidelines 1.
From the FDA Drug Label
INDICATIONS & USAGE 1. 1 Hypertension Lisinopril tablets USP are indicated for the treatment of hypertension in adult patients and pediatric patients 6 years of age and older to lower blood pressure. The patient has a blood pressure of 192/105 mmHg, which indicates hypertension. The most appropriate next step is to order initial laboratory tests to evaluate the patient's condition and guide further management. The best answer is A. order a complete blood count, urinalysis, basic metabolic profile, lipid level, and ECG 2.
From the Research
Patient Evaluation
The patient presents with elevated blood pressure (192/105 mmHg) and a history of drinking several cups of coffee every morning. The physical examination reveals clear lungs, no carotid, abdominal aortic, or femoral bruits, and chronic tissue texture abnormalities at T2-T4.
Diagnostic Approach
Given the patient's elevated blood pressure, the most appropriate next step is to order a series of laboratory tests to evaluate the patient's overall health and potential underlying conditions contributing to the hypertension. The options include:
- A. order a complete blood count, urinalysis, basic metabolic profile, lipid level, and ECG
- B. order a highly sensitive C-reactive protein level and a serum homocysteine level
- C. order echocardiography and carotid ultrasonography
- D. refer this patient to a cardiologist for an exercise stress test
- E. transport the patient to the emergency department immediately
Recommended Tests
The complete blood count (CBC) is a fundamental laboratory test that provides valuable information about the patient's hematologic status 3. Additionally, a urinalysis, basic metabolic profile, lipid level, and ECG can help identify potential underlying conditions contributing to the hypertension, such as kidney disease, electrolyte imbalances, or cardiac abnormalities 4.
Next Steps
Based on the patient's presentation and the recommended tests, the most appropriate next step is to:
- Order a complete blood count, urinalysis, basic metabolic profile, lipid level, and ECG (Option A) to evaluate the patient's overall health and potential underlying conditions contributing to the hypertension.