In general, the BP measurement should be obtained from the arm that yields the higher readings. Standing BP levels should be checked during the initial evaluation and after drug titrations to exclude significant orthostasis. Arteriolar narrowing, arteriovenous nicking, hemorrhages, exudates, or papilledema on funduscopic examination suggests poor BP control and target-organ damage. Carotid or femoral bruits or diminished peripheral pulses indicate atherosclerotic obstructive disease. An S4 gallop is often heard in patients with long-standing hypertension.
Ventricular hypertrophy is suggested by a displaced or prominent precordial impulse.
Congestive heart failure is indicated by pulmonary rales, jugular vein distention, and an S3 gallop. Signs of secondary causes of hypertension include abdominal bruits in renal artery stenosis and truncal obesity, excessive hair growth, abdominal striae, and a so-called buffalo hump in Cushing's syndrome. Blood urea nitrogen and serum creatinine levels should be obtained to quantify renal function. Urine should be analyzed for microalbuminuria, one of the earliest signs of hypertensive renal disease. Serum potassium should be checked to rule out hypokalemia suggestive of aldosteronism.