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