NYU Medical Grand Rounds Clinical Vignette

Karyn Singer, PGY3

September 22, 2010

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• The patient is a 39 year old Spanish-speaking male who presented to Bellevue Medical Consult Clinic for follow up care after presenting to Bellevue Hospital’s emergency room complaining of headache for two weeks.

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• The patient was diagnosed with high blood pressure five years ago at a health fair, when he first moved to the United States from Mexico.

• At that time, he was sent to a local public health clinic where he was started on two antihypertensive medications, which he took for two months and then stopped because he felt well.

• The patient was unable to recall the names of his medications.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•Several months prior to presentation, the patient began to experience mild, intermittent headaches.

•He described them as moderate in intensity, frontal in location, and throbbing in nature.

•Two weeks prior to presentation, his headaches worsened, increasing in intensity, frequency, and duration.

•At the insistence of the patient’s wife that he be seen by a physician, the patient presented to the emergency department for evaluation.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•In the emergency department, the patient’s blood pressure was found to be 205/110, and his heart rate was 84 beats per minute.

•His physical exam was otherwise normal

•A non-contrast cat scan of the head at the time found no evidence of an acute intracranial process, and an electrocardiogram showed normal sinus rhythm with left ventricular hypertrophy.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•Labs from the emergency room were notable for:• Creatinine 1.7, BUN 28.

•He was given the following medications:• Acetaminophen 650mg as needed for pain• Labetalol 600mg twice daily• Amlodipine 5mg daily

•The patient was discharged from the emergency room with close follow-up in medical consult clinic four days later.

Additional History

Past Medical History: •Hypertension•Obesity

Past Surgical History: Denies

Social History:•The patient moved to the United States from Mexico approximately five years ago.  He lives with his wife and four year-old son in Queens.•He works in an Italian restaurant as a busboy•He smoked half pack of cigarettes daily for three years, quit in March 2009.  He drinks roughly six beers daily on the weekends with friends.  Denies illicit drugs.

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Additional History

Family History:•Mother: Hypertension, Diabetes without complications, is currently 62 years old•Father: Alive and well, currently 64 years old

Allergies: No known drug allergies

Medications: •Acetaminophen 650mg as needed for pain•Labetalol 600mg twice daily•Amlodipine 5mg daily

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Physical Examination

General: Obese male speaking in full sentences in no acute distress.

VS: BP 160/90, HR 74, T 98.2  RR 14  BMI 34.6

Remainder of exam within normal limits.

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Laboratory Findings

•CBC within normal limits

•Basic metabolic panel:  Creatinine 1.9, BUN 30Remainder of basic was within normal limits

•Hepatic Panel within normal limits

•Lipid Panel:  Total Cholesterol 180 (<200), LDL 105 (<130), HDL 45 (38-92), Triglycerides 116 (55-250)

•Hemoglobin A1c: 5.5% (<5.7)

•Urinalysis: Trace protein, otherwise within normal limits.

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Interim History

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•During his follow-up appointment in medical consult clinic, the patient was asymptomatic and reported compliance with his medications.

•At this time, the amlodipine was increased to 10mg daily, and lisinopril 10mg daily was started.

•The patient was given one refill of each prescription, and was given a medical clinic follow-up appointment for two months later.

Interim History

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•Two months later, the patient presented to primary care clinic to re-establish care and to follow-up his hypertension.

•He reported that he felt well but had not been taking his medication for the past month because he did not realize he had a refill left on his prescription.

•At this time, the patient’s blood pressure was noted to be 190/105

• Advanced, uncontrolled hypertension with end-organ damage due to an inability to navigate the healthcare system.

Final Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

MAX TRUBEK, M.D.

November 28, 1898

to March 31, 2001

Reading EKGs in his office

at the age of 90