A 46-Year-Old Woman Comes to the Clinic for Follow-Up Treatment

question 899

Multiple Choice

A 46-year-old woman comes to the clinic for follow-up treatment of hypertension.  The patient was diagnosed with hypertension 2 years ago and nonpharmacological management was initially advised.  A year ago, she was started on valsartan and amlodipine after her blood pressure was measured at 144/86 mm Hg.  A month after treatment initiation, she reported no adverse effect from the medication and blood pressure was 130/80 mm Hg.  Since then, the patient has missed several follow-up appointments, which she attributes to being busy at work.  She currently has no concerns and overall feels "great."  She has had no chest pain, headaches, lightheadedness, or syncope.  The patient has no other medical issues and does not use tobacco or alcohol.  She works as a salesperson and eats fast food a few times a month.  Her mother died of a stroke at age 67.  Today, blood pressure is 152/88 mm Hg in the right arm and 148/86 mm Hg in the left arm; pulse is 76/min and regular.  Repeat blood pressure measurements after 15 minutes of rest are similar.  BMI is 28 kg/m².  Estimated jugular venous pressure is normal.  There are no carotid bruits.  Heart sounds are normal with no murmurs.  Lung examination is unremarkable.  Peripheral pulses are full and symmetric.  There is no peripheral edema.  Laboratory results are as follows: ECG shows normal sinus rhythm with nonspecific T-wave changes.  Which of the following is the best next step in management of this patient?

• A)Add chlorthalidone to her medical regimen and follow up
• B)Encourage low-salt diet and follow up in 6-8 weeks
• C)Initiate workup for secondary hypertension
• D)Obtain 24-hour ambulatory blood pressure monitoring
• E)Reinforce education about hypertension and treatment goals

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