A 62-Year-Old Man Returns for Evaluation of Hypertension

question 154

Multiple Choice

A 62-year-old man returns for evaluation of hypertension.  For the past year, his blood pressure has become increasingly difficult to control despite the addition of several antihypertensive medications.  He also has type 2 diabetes mellitus, intermittent claudication, erectile dysfunction, hyperlipidemia, and coronary artery disease.  Currently he takes metoprolol, amlodipine, hydrochlorothiazide, lisinopril, and hydralazine for hypertension.  The patient smokes cigars daily and drinks alcohol socially.  His blood pressure is 165/95 mm Hg, and pulse is 76/min.  On examination, the point of maximal impulse is palpated lateral to the midclavicular line on the left.  Heart sounds are normal.  A bruit is heard on auscultation to the left of the umbilicus.  There is trace pedal edema.  The distal pulses of the lower extremities are diminished bilaterally.  Laboratory results are as follows: Which of the following is the most appropriate next step in management of this patient?

• A)Obtain abdominal duplex Doppler ultrasonography
• B)Obtain serum aldosterone level
• C)Proceed with angiography of the renal arteries
• D)Start losartan
• E)Start spironolactone