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