Transcript Journal Club

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