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Cases
Exertional Fatigue
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Background
A 64-year-old white man presents to his physician with exertional fatigue that has lasted 3 weeks. He has a 10-year history of type 2 diabetes mellitus, which is being treated with oral hypoglycemic medications. He also reports some exertional dyspnea but denies having any angina, orthopnea, or paroxysmal nocturnal dyspnea (PND). He has no history of coronary artery disease (CAD) or chronic obstructive pulmonary disease (COPD).
Three years ago, the patient was treated for hypertension with an angiotensin-converting enzyme (ACE) inhibitor, but he stopped taking the medication after a dry cough developed. The patient states that his physician at that time rechecked his blood pressure and elected not to restart any antihypertensive medication. According to the patient, his blood pressure has been normal since then. On presentation, his pulse is 88 beats per minute and regular, his respirations are 22 breaths per minute, and his blood pressure is 164/100 mm Hg. His physical examination is remarkable for an apical S3 gallop with occasional premature beats on cardiac auscultation and mild bibasilar rales with decreased breath sounds on pulmonary auscultation. His point of maximum impulse (PMI) is diffuse. He has no jugular venous distension. His ECG and 2-dimensional (2D) echocardiogram are as shown. What is the diagnosis?
The patient began to have severe fatigue and hot flashes due to goserelin. After a full discussion with the urologist, he consented to orchiectomy. Six months later, he began to have pain in his right eye and pain, swelling, and a headache in the right orbital area. The patient was evaluated by an otolaryngologist, who treated him for sinusitis and performed surgery to correct his deviated septum. These treatments provided some relief of his symptoms for a few weeks. However, the patient later felt fullness in his eye and went to an ophthalmologist, who found no retinal or choroids lesion. The patient's visual acuity was normal.
He then went to an oncologist, who ordered diagnostic tests, including orbital CT and bone scanning. What is the diagnosis?
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***** HINT *****
Look carefully at the images. The 2D echocardiographic and ECG findings are critical to the diagnosis.
***** ANSWER *****
Hypertension with mild decompensated congestive heart failure (CHF) due to hypertensive heart disease: This patient has decompensated CHF in the presence of inadequately controlled hypertension, which undoubtedly has not been adequately controlled for many years. The short-axis 2D echocardiogram depicts concentric left ventricular hypertrophy (LVH). His 12-lead ECG shows LVH and ST-T repolarization abnormalities typical of long-standing hypertension. In addition, the patient's chest radiograph depicts a normal-sized cardiac silhouette and Kerley B lines in both bases, which suggest left atrial enlargement and mild pulmonary venous congestion. These findings further support the diagnoses.
Patients with diabetes mellitus frequently have hypertension, or hypertension eventually develops. Long-standing hypertension results in an increased left ventricular (LV) wall thickness with diastolic dysfunction and an elevated LV end-diastolic pressure, which is exacerbated by acute elevations of blood pressure. Patients with this condition may have silent myocardial ischemia, which results in increased blood pressure with exacerbation of diastolic dysfunction, leading to decompensated CHF.
Decompensated CHF can quickly be resolved with intravenous loop diuretics, such as furosemide or bumetanide. However, antihypertensive therapy is required to prevent further episodes of decompensated CHF, to reverse end-organ damage to the heart, and to reduce LV wall thickness and diastolic dysfunction.
In this diabetic patient with a history of dry cough resulting from ACE-inhibitor therapy, angiotensin II antagonists (eg, candesartan, Atacand) are particularly useful in reversing end-organ damage, reducing LV wall thickness, and improving LV diastolic function. Furthermore, angiotensin II antagonists are useful in reducing the risk of diabetic nephropathy and preserving renal function in diabetic patients. Angiotensin II antagonists are also effective for normalizing blood pressure in patients with hypertension and hypertensive heart disease, with or without diabetes mellitus.
For more information about hypertension and CHF, please see the eMedicine articles Hypertension, Hypertension, Malignant, Heart Failure, and Congestive Heart Failure and Pulmonary Edema.
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Author:
Michael E. Zevitz, MD
Clinical Assistant Professor, Department of Medicine, Chicago Medical School
eMedicine Editor:
Nicholas Lorenzo, MD
Chief Publishing Officer, eMedicine.com
Source
http://emedicine.com
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