NYU Medical Grand Rounds Clinical Vignette Krista Michelin MD, PGY-3 March 17, 2010 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

A 60-year-old man with hypertension and hyperlipidemia presents for routine follow-up of his chronic medical conditions. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS The patient was in his usual state of health until his late forties when he was diagnosed with hypertension and hyperlipidemia. For the first several years after his diagnosis, the patient was managed with therapeutic lifestyle changes including diet modification and jogging. Despite a healthier lifestyle, after several years the patient’s LDL cholesterol and blood pressure reached levels requiring pharmacotherapy.

History of Present Illness The patient was started on hydrochorothiazide and a statin. His medications were titrated over the next year, and recommended blood pressure and lipid goals were eventually achieved. The patient’s blood pressure and lipids have been stable over the last four years without additional changes to his medical regimen. He has no complaints since his last visit three months ago and reports good medication compliance. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Additional History U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Past Medical History Hypertension Hyperlipidemia Anxiety disorder Past Surgical History None Family History Father: Coronary disease CABG at age 62 Mother: Hypertension Social History Lives with his wife Practicing attorney Lifetime non-smoker Social alcohol use Denies illicit drug use

Outpatient Medications U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Aspirin 81mg daily Atorvastatin 20mg daily Losartan-Hydrochlorothiazide mg daily Paroxetine 30mg daily Allergies: Sulfa (rash)

Physical Examination U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS General: Well-appearing man in no acute distress Vitals: T 98F, BP 118/71, HR 75, RR 16, BMI 29 O 2 saturation: 99% on room air The remainder of the physical exam was normal

Laboratory Studies U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS CBC: Within normal limits Basic Metabolic Panel: Within normal limits Hepatic Panel: Within normal limits Total cholesterol: 175mg/dL (0-200 mg/dL) HDL cholesterol: 51md/dL (30-74 mg/dL) Triglycerides: 91mg/dL ( mg/dL) LDL cholesterol: 106mg/dL (<130 mg/dL)

Working Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Well-controlled hypertension and hyperlipidemia on stable medical therapy

U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS During the patient’s visit On review of the patient’s medical record, the patient’s blood pressure measurements and lipid profiles at each visit have been normal at three month intervals for the last four years. Later during the visit, the patient expresses concern that he is reaching the age at which his father underwent bypass surgery. He requests referral to a cardiologist and for CT coronary angiography.

U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS During the patient’s visit When asked about chest discomfort or dyspnea on exertion, the patient reports jogging around the Central Park Reservoir without difficulty last weekend (1.58 miles). Despite reassurances, he is remains anxious about his risk and says he may look for a second opinion. As a compromise, an ECG is obtained. It is normal. A follow-up appointment in three months is arranged with routine blood work, including a fasting lipid profile and ECG.

U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Final Diagnosis Well-controlled hypertension and hyperlipidemia on stable medical therapy Apprehension regarding cardiovascular risk and family history of coronary artery disease

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