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NYU Medical Grand Rounds Clinical Vignette

NYU Medical Grand Rounds Clinical Vignette. Albert Ahn, MD (PGY3) Tuesday, February 21, 2012. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. Chief Complaint. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.

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NYU Medical Grand Rounds Clinical Vignette

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  1. NYU Medical Grand Rounds Clinical Vignette Albert Ahn, MD (PGY3) Tuesday, February 21, 2012 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  2. Chief Complaint UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • This is 64 year-old woman who presents to medicine clinic for routine examination

  3. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • In 2001, she was diagnosed with ductal carcinoma in-situ of her right breast. She underwent right mastectomy. Reports having “excellent health” since then. • Recently she has been splitting her nifedipine tablets in half because they were “making me feel dizzy”. She takes her blood pressure daily with a home machine. She brings a blood pressure log. It ranges from 120s-130s/60s-70s.

  4. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Past Medical History: • DCIS of right breast in 2001 • Asthma • Hypertension • Hyperlipidemia • Past Surgical History: • Right mastectomy in 2001 • Social History: • Denies tobacco use, but lived with a long-time smoker. Rare alcohol use. No illicit drug use. • Born in Norway, emigrated to US in the 1950s • Family History: • Father with diabetes and coronary heart disease

  5. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Additional History • Allergies: • Tetracycline – rash • Medications: • Nifedipine XL 60 mg by mouth daily • Fluticasone/salmeterol 500-50 mcg inhaler, 1 puff twice daily • Albuterol inhaler, 2 puffs every 4-6 hours as needed

  6. Physical Examination UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • General: anxious-appearing • Vital Signs: • T: 98.4 BP: 178/90 HR: 92 RR: 16 • Cardiac exam with III/VI systolic ejection murmur heard best at left upper sternal border • Remainder of Physical Exam was normal

  7. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • CBC: within normal limits • Basic Metabolic panel: within normal limits • Hepatic panel: within normal limits • Thyroid Stimulating Hormone: 2.47mU/L (0.35 – 4.8) • Hemoglobin A1C: 6.2% (<5.7%) • Lipid panel: • LDL 173mg/dL (</=130) • Total Cholesterol 253mg/dL (</=200) • Microalbumin/Creatinine Ratio: 8.2 (</=20)

  8. Other Studies UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • ECG: sinus rhythm at 91 beats per minute • Chest X-Ray: flattening of the diaphragm with good inflation of lungs. Examination otherwise unremarkable. • Transthoracic echocardiogram: hyperdynamic left ventricle, increased ejection fraction, otherwise normal examination

  9. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Working Diagnosis • Hypertension with medication non-adherence or white coat effect • Pre-diabetes • Hyperlipidemia

  10. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Treatment Course • Initial visit: • Nifedipine XL was decreased to 30mg daily. Instructed not to split these tablets and to stop medication if she felt lightheaded again • Instructed to continue blood pressure log • Referred for 24-hour ambulatory blood pressure monitoring

  11. Ambulatory Blood Pressure Report

  12. Ambulatory Blood Pressure Report

  13. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Final Diagnosis • Mild 24-hour isolated systolic hypertension (143/78 mmHg)) with white coat effect (227/116 mmHg) • Pt was switched to lisinopril 10mg daily with close follow-up

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