Case Presentation: Mr' X

1
Case PresentationMr. X

• Lee Pierson
• Medical Student
• University of North Carolina

2
Chief Complaint

• I have been having unusual shortness of breath
  when I walk the dog, and it seems to be getting
  worse.

3
History of Present Illness

• 55 year old Caucasian male presents with a
  complaint of progressive dyspnea over the past 2
  years.
• Dyspnea is associated with mild exertion and is
  relieved by rest.
• Dyspnea is not associated with pain, cough, or
  fever.
• Patient reports non-compliance with medications.

4
Past Medical History

• History of hypertension (diagnosed in 1980).
• History of hyperlipidemia (diagnosed in 1995).
• Obesity

5
Allergies and Medications

• Allergies
• No known drug allergies.
• Medications
• Toprol 50 mg q.d.
• Lipitor 20 mg q.d.

6
Social History

• Medications Other Substances
• Non-compliant with medications. Does not smoke,
  drink alcohol or coffee, or use drugs.
• Exercise Diet
• He does not exercise and eats a diet high in fat
  and salt.
• Work Home Life
• He works at a sedentary job and lives with his
  wife and daughter.

7
Family History

• Father hypertension and hyperlipidemia died of
  myocardial infarction at age 55.
• Mother hypertension died of stoke at age 60.
• Brother (57 y/o) has hypertension
• Sister (53 y/o) has hypertension
• Daughter (20 y/o) apparently healthy

8
Vital Signs

• Vital Signs
• Blood Pressure 170/94 mmHg
• Pulse 80 bpm
• Temperature 98.6 F
• Respirations 16 bpm
• Height 70 inches
• Weight 250 lbs
• Body Mass Index 35.9 kg/m2

9
Physical Exam

• Observation Caucasian male, in no acute
  distress appears stated age obesity with
  android body fat distribution.
• Palpation Prominent apical cardiac impulse with
  mild lateral displacement
• Auscultation S1/ S2 with regular rhythm and rate
  noted at apex, without murmurs or rubs. An S4
  heart sound was appreciated.
• Percussion Resonance noted over all lung fields.
  

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Laboratory Values
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Chest X-Ray
Mr. Xs chest film shows cardiomegaly.
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Electrocardiogram
Increased voltage with ST strain pattern is
highly indicative of left ventricular
hypertrophy.
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Echocardiogram
Apical 4 Chamber View
The LV cavity is a normal size, but there is
moderate left ventricular hypertrophy
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Echocardiogram
This is concentric LV hypertrophy. The
ventricular walls measure 1.4 cm thick.
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Echocardiogram
Pulsed Doppler Flow Velocity across the Mitral
Valve For Assessment of Early to-Late Diastolic
LV Filling (E/A Ratio).
There is a diminished E-wave with a prominent
A-wave.
This pattern is consistent with diastolic
dysfunction.
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Assessment/Differential Diagnosis

• The physical exam findings of uncontrolled
  hypertension in the presence of an S4 heart
  sound, with laterally displaced and increased
  apical impulse suggests left ventricular
  hypertrophy.
• The further findings of cardiomegaly on chest
  x-ray, and increased voltage with ST segment
  strain pattern on EKG add to the evidence
  suggesting left ventricular hypertrophy.

17
Assessment/Differential Diagnosis

• The echocardiogram images confirm the diagnosis
  of concentric left ventricular hypertrophy
  (showing increased LV wall thickness in relation
  to chamber cavity).
• The abnormal early-to-late filling ratio (E/A
  ratio) found in diastole with the pulsed doppler
  suggests that Mr. X has diastolic dysfunction
  related to left ventricular hypertrophy.

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Pathophysiology of Diastolic Dysfunction
Hypertension
Cardiac Structural Changes (LV Hypertrophy)
Diastolic Dysfunction
19
Treatment Plan

• Angiotenson Converting Enzyme Inhibitors (ACE
  Inhibitors) have been shown to be effective in
  reducing BP and regressing LVH.
• Beta Blockers reduce BP but also lower heart
  rate, thus allowing more LV diastolic filling
  time.
• Plan to start patient on lisinopril (ACE
  inhibitor) and increase dose of Toprol (Beta
  Blocker).
• This plan should reduce BP, over time regress
  LVH, and improve diastolic dysfunction.

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Treatment Plan

• Schedule a follow-up appointment with Mr. X in 2
  weeks to re-check blood pressure after starting
  medications.

Hopefully Mr. X will start to feel better soon!