NYU Medical Grand Rounds Clinical Vignette Albert Ahn, MD (PGY3) Tuesday, February 21, 2012 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS
NYU Medical Grand Rounds Clinical Vignette
Albert Ahn, MD (PGY3)
Tuesday, February 21, 2012
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• This is 64 year-old woman who presents to medicine clinic for routine examination
Chief Complaint
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.
History of Present Illness
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Additional History
•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
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
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Physical Examination
•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
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Laboratory Findings
•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)
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Other Studies
•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
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• Hypertension with medication
non-adherence or white coat effect
• Pre-diabetes
• Hyperlipidemia
Working Diagnosis
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• 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
Treatment Course
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Ambulatory Blood Pressure Report
Ambulatory Blood Pressure Report
• 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
Final Diagnosis
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS