Transcript NYU Medical Grand Rounds Clinical Vignette Albert Ahn, MD (PGY3)

NYU Medical Grand Rounds
Clinical Vignette
Albert Ahn, MD (PGY3)
Tuesday, February 21, 2012
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• This is 64 year-old woman who presents to
medicine clinic for routine examination
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• 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/60s70s.
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
Working Diagnosis
• Hypertension with medication
non-adherence or white coat effect
• Pre-diabetes
• Hyperlipidemia
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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Ambulatory Blood Pressure Report
Ambulatory Blood Pressure Report
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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS