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Clinical Correlations
The NYU Internal Medicine Blog
A Daily Dose of Medicine
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UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
NYU Medicine Grand Rounds
Clinical Vignette
Todd Cutler, MD
PGY-2
December 15, 2010
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• The patient is a 67 year-old African
American man who presents to a primary
care provider for his annual evaluation.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•The patient notes a longstanding history of
hypertension, but has persistently refused to take any
additional recommended medications.
•He has stated in the past that he would like to try
various homeopathic remedies prior to initiating any
new medications.
•He currently denies any complaints.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Past Medical History:
•Hypertension – diagnosed 30 years ago
•Diabetes – diagnosed 22 years ago
•Hypercholesterolemia – diagnosed 22 years ago
•Hepatitis C – unknown age at time of contraction
•Past Surgical History:
•none
•Social History:
•Former heroin user, quit 30 years ago. Denies all other toxic habits.
•Is a retired baker. Lives with his ex-wife.
•Family History:
•None
•Allergies:
•No known drug allergies
•Medications:
•Amlodipine 10mg daily
•Glyburide 5mg twice daily
•Metformin 500mg twice daily
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
•General: well-appearing and in no distress
•Vital Signs: T: 98.2 BP: 186/80 HR: 71
•Remainder of physical exam was normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•Complete Blood Count:
•White Blood Cell Count 3,000 cells/cmm
•Hemoglobin: 13 g/dL
•Hematocrit: 39 %
•Platelets: 121,000 cells/cmm
•Basic Metabolic panel: glucose 175 mg/dL
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•Hepatic panel:
•AST: 66 units/L (11-39)
•ALT: 73 units/L (11-35)
•Alkaline phosphatase: 131 units/L (25-100)
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•Hemoglobin A1c: 8.3% (<5.7%)
•Urine microalbumin/creatinine ratio: 71.0 (<30)
•Hepatitis C antibody: reactive
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working Diagnosis
• Stage II hypertension, uncontrolled, in part,
due to suboptimal medical therapy.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Follow-Up Evaluation
• Despite his continued hypertension, evidence of
proteinuria, and elevated hemoglobin A1c, after
a prolonged discussion the patient did not wish
to add any additional medications to his
hypertension and diabetes drug regimens,
respectively.
• He agreed to return to clinic in three months for
a follow-up appointment.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Follow-Up Evaluation
• On follow-up, his physical exam was notable for a blood
pressure of 200/79.
• The patient reported feeling well and that his blood
pressure on his home monitor was “2-3 times lower” than
the readings in clinic.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Follow-Up Evaluation
• He again stated that despite the risks associated with
such a markedly elevated blood pressure, he required no
further changes in his medication regimen.
• He was, however, willing to continue taking the
medications that were previously prescribed.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Follow-Up Evaluation
• The patient was told to come to the emergency
department if he experienced chest pain, shortness of
breath, headaches or blurry vision.
• A follow-up appointment was given in three months, and
the patient was asked to bring his home blood pressure
monitor to his next clinic appointment.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Stage II, uncontrolled hypertension,
complicated by proteinuria, in the context
of suboptimal medical therapy.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS