Adi Kartolo

University of Ottawa

Initial Presentation

• 42-year-old African-American male with type 2 diabetes

• Chief Complaint: increasing body weight (15 pounds) and increasing fatigue over the past 12 weeks, having hard time walking one flight of stairs or over three blocks to the neighbourhood grocery store.

Hx

Past medical Hx: • 8 mg rosiglitazone and 10 mg clozapine daily• Diagnosed with hypertension at the age of 32• Hospitalized with acute psychosis 28 years ago

(no recent relapses)• A history of schizophrenia and stroke

Hx cont’d

Family Hx: • Father died with end-stage renal disease and

sudden cardiac death at age 53• Mother is alive but has diabetes, hypertension

and a previous stroke at age 74

Hx cont’d

Social/Occupational Hx:• Short-order cook at a local cafeteria• Sedentary lifestyle with no recreational

physical activity at all• Smokes one pack of cigarettes/day for 31 yrs• Doesn’t consume alcohol anymore (heavy

alcohol use 12 years prior)• No recent history of substance abuse

Physical Findings

• BMI: 32.6 (height 70 inches; weight: 227 lbs)• Waist circumference: 42 inches• BP: 154/96 mmHg• HR: 84 irregular beats/minute• RR: 12 breaths/minute• Normal body temperature

DDx

• What test should we order?• What organs should we check for?

More Examination

• Lungs are clear to auscultation and percussion, no rales or wheezes

• No focal motor or sensory deficits• No tumor or lesion found• BP remains at around 154/96 mmHg

Blood Test

Lipid:• Triglycerides = 163 mg/dl (normal: 90-150)• Cholesterol= 240 mg/dl (normal: less than

200)• HDL = 54 mg/dl (normal: 44 for male; 55 for

female)• LDL = 153 mg/dl (normal: 130, borderline:

130-159, high risk: 160 and above)

Blood Test Cont’d

• HbA1C = 7.6% (less than 7% is normal; above 9% shows poor control; above 12% shows very poor control)

• Serum creatinine = 1.1 mg/dl (normal value = 0.8-1.4 mg/dl)

Blood Test Cont’d

• GFR= 95 ml/min/1.73 m2

• Reference tableAge (years) Mean eGFR

20-29 116 mL/min/1.73 m2

30-39 107 mL/min/1.73 m2

40-49 99 mL/min/1.73 m2

50-59 93 mL/min/1.73 m2

60-69 85 mL/min/1.73 m2

70+ 75 mL/min/1.73 m2

Echocardiography

• Ef = 58% (normal range 55-70%)• Mitral valve Doppler pattern consistent with

mild diastolic dysfunction.• Slightly enlarged left ventricle

Diagnosis!!

???

Diagnosis

• Hypertensive heart disease (at risk) complicated by diabetes mellitus

• May have some degree of coronary artery disease

• At risk for pulmonary edema due to hypertensive heart disease

Treatment

???

Treatment

• Referral to a nutritionist for diet program• Monitored exercise program• Statin therapy• Anti-diabetic medication• Combination anti-hypertensive therapy