1. NYU Medical Grand Rounds Clinical Vignette Albert Ahn, MD (PGY3) Tuesday, February 21, 2012 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. This is 64 year-old woman who presents to medicine clinic for routine examination Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

4. 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

6. 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. 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) U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. Hypertension with medication non-adherence or white coat effect Pre-diabetes Hyperlipidemia Working Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

10. 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

11. Ambulatory Blood Pressure Report

13. 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS