This patient requires antihypertensive therapy for persistent mild hypertension. He previously developed tongue swelling on ramipril , consistent with ACE inhibitor–induced angioedema , which is a contraindication to further ACE inhibitor use (e.g., enalapril). MCCQE objectives emphasize avoiding re-exposure to ACE inhibitors after angioedema due to risk of recurrence, which can be life-threatening.

Beta-blockers such as metoprolol are not first-line for uncomplicated hypertension and should be used cautiously in patients with asthma due to risk of bronchospasm (even though cardioselective agents are safer, alternatives are preferred). Clonidine and hydralazine are not first-line agents for chronic management due to side effects and rebound hypertension risk.

A thiazide diuretic (hydrochlorothiazide) is an appropriate first-line therapy for uncomplicated hypertension. Thiazides have strong evidence for cardiovascular risk reduction and are suitable in patients without contraindications.

Thus, hydrochlorothiazide is the most appropriate initial therapy in this patient.

This presentation is classic for an undiagnosed pheochromocytoma, which causes episodic or crisis-level hypertension due to excess catecholamines. Anesthesia or surgical manipulation can trigger massive catecholamine release, leading to hypertensive crisis. Phentolamine, an alpha-blocker, is the appropriate treatment.

Toronto Notes 2023 – Endocrinology, Pheochromocytoma:

“Pheochromocytomas may precipitate hypertensive crises during surgery. Elevated plasma catecholamines and urinary metanephrines confirm diagnosis.”

MCCQE1 Objectives – Internal Medicine > Endocrinology:

“Candidates should suspect pheochromocytoma in perioperative hypertensive crises and confirm with plasma or urine catecholamines/metanephrines.”

Low metanephrines (E) would argue against pheochromocytoma. TSH (A), cortisol (D), and renin (C) are unrelated to acute intraoperative hypertensive episodes of this nature.

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When a screening program is introduced, the incidence rate appears to rise because more cases (including subclinical ones) are identified earlier. This is known as “lead-time bias” or “ascertainment bias.”

Toronto Notes 2023 – Public Health, Screening and Epidemiology:

“Screening increases the apparent incidence of disease as more early or latent cases are detected.”

MCCQE1 Objectives – Preventive Medicine > Screening:

“Candidates should understand how implementation of screening programs affects disease incidence and epidemiologic metrics.”

Case fatality rate (A) may decrease. PPV (B) depends on prevalence. Positive biopsy rate (C) may remain stable. Treatment rate (E) could increase, but incidence is the most directly and consistently affected.

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This patient’s lab results suggest impaired fasting glucose and an elevated A1c just below the threshold for diabetes. The gold standard to confirm diabetes in such intermediate cases is the 75 g oral glucose tolerance test (OGTT).

Toronto Notes 2023 – Endocrinology, “Diabetes Mellitus” Section:

“If A1c is in the 6.0–6.4% range or fasting glucose 6.1–6.9 mmol/L, a 75 g OGTT is recommended to establish the diagnosis of diabetes or confirm impaired glucose tolerance.”

MCCQE1 Objectives (Internal Medicine > 76-4: Diabetes):

“Candidates must correctly apply diabetes screening and diagnostic criteria and follow up abnormal results with appropriate confirmatory testing.”

Urine ACR (C) is useful in diagnosed diabetes, not for initial screening. TSH (A), capillary glucose testing (B), and exercise testing (E) are not indicated at this stage.

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