NYU Medical Grand Rounds Clinical Vignette

Krista Michelin MD, PGY-3

March 17, 2010

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

A 60-year-old man with hypertension and hyperlipidemia presents for routine follow-up

of his chronic medical conditions.

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 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.

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Additional History

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

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

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Aspirin 81mg daily

Atorvastatin 20mg daily

Losartan-Hydrochlorothiazide 50-12.5mg daily

Paroxetine 30mg daily

Allergies: Sulfa (rash)

Physical Examination

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

General: Well-appearing man in no acute distress

Vitals: T 98F, BP 118/71, HR 75, RR 16, BMI 29

O2 saturation: 99% on room air

The remainder of the physical exam was normal

Laboratory Studies

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 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 (60-290 mg/dL)

• LDL cholesterol: 106mg/dL (<130 mg/dL)

Working Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Well-controlled hypertension and hyperlipidemia on stable medical therapy

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

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.

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

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.

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Final Diagnosis

Well-controlled hypertension and hyperlipidemia on stable medical therapy

Apprehension regarding cardiovascular risk and family history of coronary artery disease

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

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