Transcript Journal Club

NYU Medical Grand Rounds
Clinical Vignette
Karyn Singer, PGY3
September 22, 2010
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• The patient is a 39 year old Spanish-speaking male who
presented to Bellevue Medical Consult Clinic for follow up
care after presenting to Bellevue Hospital’s emergency
room complaining of headache for two weeks.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• The patient was diagnosed with high blood pressure five
years ago at a health fair, when he first moved to the
United States from Mexico.
• At that time, he was sent to a local public health clinic
where he was started on two antihypertensive medications,
which he took for two months and then stopped because
he felt well.
• The patient was unable to recall the names of his
medications.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•Several months prior to presentation, the patient began to
experience mild, intermittent headaches.
•He described them as moderate in intensity, frontal in
location, and throbbing in nature.
•Two weeks prior to presentation, his headaches worsened,
increasing in intensity, frequency, and duration.
•At the insistence of the patient’s wife that he be seen by a
physician, the patient presented to the emergency
department for evaluation.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•In the emergency department, the patient’s blood pressure
was found to be 205/110, and his heart rate was 84 beats
per minute.
•His physical exam was otherwise normal
•A non-contrast cat scan of the head at the time found no
evidence of an acute intracranial process, and an
electrocardiogram showed normal sinus rhythm with
left ventricular hypertrophy.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•Labs from the emergency room were notable for:
• Creatinine 1.7, BUN 28.
•He was given the following medications:
• Acetaminophen 650mg as needed for pain
• Labetalol 600mg twice daily
• Amlodipine 5mg daily
•The patient was discharged from the emergency room with
close follow-up in medical consult clinic four days later.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
Past Medical History:
•Hypertension
•Obesity
Past Surgical History: Denies
Social History:
•The patient moved to the United States from Mexico
approximately five years ago. He lives with his wife and four yearold son in Queens.
•He works in an Italian restaurant as a busboy
•He smoked half pack of cigarettes daily for three years, quit in
March 2009. He drinks roughly six beers daily on the weekends
with friends. Denies illicit drugs.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
Family History:
•Mother: Hypertension, Diabetes without complications, is currently 62
years old
•Father: Alive and well, currently 64 years old
Allergies: No known drug allergies
Medications:
•Acetaminophen 650mg as needed for pain
•Labetalol 600mg twice daily
•Amlodipine 5mg daily
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
General: Obese male speaking in full sentences in no
acute distress.
VS: BP 160/90, HR 74, T 98.2 RR 14 BMI 34.6
Remainder of exam within normal limits.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•CBC within normal limits
•Basic metabolic panel:
Creatinine 1.9, BUN 30
Remainder of basic was within normal limits
•Hepatic Panel within normal limits
•Lipid Panel: Total Cholesterol 180 (<200), LDL 105 (<130),
HDL 45 (38-92), Triglycerides 116 (55-250)
•Hemoglobin A1c: 5.5% (<5.7)
•Urinalysis: Trace protein, otherwise within normal limits.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Interim History
•During his follow-up appointment in medical consult clinic,
the patient was asymptomatic and reported compliance
with his medications.
•At this time, the amlodipine was increased to 10mg daily,
and lisinopril 10mg daily was started.
•The patient was given one refill of each prescription, and
was given a medical clinic follow-up appointment for two
months later.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Interim History
•Two months later, the patient presented to primary care
clinic to re-establish care and to follow-up his
hypertension.
•He reported that he felt well but had not been taking his
medication for the past month because he did not realize
he had a refill left on his prescription.
•At this time, the patient’s blood pressure was noted to be
190/105
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Advanced, uncontrolled hypertension with
end-organ damage due to an inability to
navigate the healthcare system.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
MAX TRUBEK, M.D.
November 28, 1898
to March 31, 2001
Reading EKGs in his office
at the age of 90
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS