first question | choose another case | Epharnet

The patient presented at our outpatient clinic with occasional headaches, increased blood pressure and elevated fasting blood sugar.

Family history:
His father died of a stroke at the age of 67, mother is doing well.

Patient´s history:
6 years ago hypertension (170/105) was first found accidentally, when the patient was treated for kidney stones. At that time, his weight was 89 kg. As the nonpharmacological approach was not quite successful he was put on atenolol, 50mg OD, hydrochlorothiazide 50 mg OD and amiloride 5.0 mg OD. BP went down to 145/85-90.

About 4 years ago he underwent an attack of back pain which was treated as renal colic. Apart from that he has never had any attacks of dysuria or unexplained fever.

Some two years ago, when being stressed by family and occupational problems, he did not take treatment quite regularly and his BP was 200/105. Urine sample analysis showed normal biochemistry, slightly elevated number of white blood cells and a specific gravity of 1017. Plasma sodium and potassium measures and those of creatinine within normal limits. Uric acid was 511 mmol/L (n < 480), urea 9.2 (n < 7.1) and glucose 6.0 mmol/L. There was slight elevation of total cholesterol, LDL cholesterol and triacylglycerols with HDL cholesterol being just within normal limits.

He was diagnosed with abdominal type of obesity, dyslipidaemia and hypertension (possible metabolic syndrome with normal fasting blood glucose level). Despite this, treatment with beta-blockers and diuretics was continued. Interstitial nephropathy was considered. A calcium channel blocker was contemplated as the next drug if blood pressure control would be unsatisfactory.

Nowadays, the patient was sent to our outpatient clinic for hypertension and elevated fasting blood sugar (8.1 and 7. 5 mmol/L on repeated examinations).

The patient requests being examined in absence of the nurse (!!). After she leaves, he says that he has been quite happy recently, after he found a new girlfriend, who he would like to marry soon. Then he claims to have got an impression that full treatment of hypertension might interfere with his sexual function: sexually he seems to do better when being off treatment. He is a nonsmoker.

Physical examination:
an obese 54 years old gentleman, the height is 175 cm, weight 94 kg, BMI 30, abdominal type obesity. BP : 170/100-105. There is no bruit on his back or over abdomen and all peripheral arteries are well palpable. Plasma sodium and potassium measures are within normal limits. Plasma uric acid 511 mmol/L, creatinine 115 mmol/L and urea 9.7 (n < 7.1) mmol/L. Lipids: total cholesterol 7.07, LDLch 4.01, HDLch 0.85, and TAG 2.62 - all in mmol/L, fasting blood glucose 8.3 mmol/L. Urine sample: specific gravity 1.025, normal white blood cell count. Protein 400 mg/day on a first measurement and 550 mg a week later.

Diagnosis:
Obesity, abdominal type. Metabolic syndrome. Diabetes mellitus, type II. Erectile dysfunction.