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