first question | choose another case | Epharnet

Thirty four year old man was referred to our department for breathing difficulties that have been progressing during the last 3 months, developing from dyspnea on exertion to orthopnea.

Family history:
Both his parents and his older brother are alive, doing well and not having any problems with blood pressure.

Personal history:
His medical history was unique with a stroke at the age of 31. He has been aware of his elevated blood pressure (BP) for about 10 years.

Physical examination:
On examination, we found an uncontrolled arterial hypertension (200/125 mmHg), distended jugular veins, and questionable pretibial oedema.

Examinations:
- On the chest X-ray the heart was not enlarged and the cardiothoracic ratio still normal but there were definite signs of pulmonary congestion.
- There were no abnormalities on ECG apart from signs of left ventricular hypertrophy.
- Echocardiography (ECHO) showed hypertrophy of the interventricular septum (15-mm) and posterior wall of the left ventricle, a normal left ventricular ejection fraction (LVEF) - 62% and a normal size of the left atrium (32-mm).
- Biochemistry revealed a borderline concentration of serum creatinine (113 µmol/L). Serum Na+ was 143 mmol/L, K 3.5 mmol/L and calcium 2.61 mmol/L.
- Urine analysis showed no significant abnormalities.
- The blood gasses were normal.

Treatment with an ACE-I trandolapril, 2mg/day (angiotensin converting enzyme inhibitor) and a diuretic was started. Signs of congestion disappeared but BP remained elevated (170/120 mmHg). Serum creatinine level rose to 142 mmol/L.