1 / 13

Clinical Case 2

Clinical Case 2. Andrew J Coats Norwich Research Park, Norwich, UK. Relevant disclosure of interest: Consultant to Daiichi Sankyo and the Menarini group. Presentation. Patient requested a specialist consultation

hamal
Download Presentation

Clinical Case 2

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Clinical Case 2 Andrew J Coats Norwich Research Park, Norwich, UK Relevant disclosure of interest: Consultant to Daiichi Sankyo and the Menarini group

  2. Presentation • Patient requested a specialist consultation • her own self-monitored systolic BP has been consistently above 160 mmHg (which she had read was too high) • she had noticed increasing shortness of breath and early morning wheeze and coughing • GP reassured patient that her BP was adequately controlled because her diastolic BP had mostly been below 80 mmHg

  3. History Taking • Mrs HK is a 74 year old Finnish diplomat’s wife who has lived in London for the last 4 years • She is active • An ex-smoker • Known and treated hypercholesterolaemia • Elevated fasting glucose levels noted recently • Family history: • premature ischaemic heart disease (father and two brothers) • stroke (mother)

  4. History Taking - 2 • 5 years previously she had two TIAs and one more prolonged ischemic episode that left her with a minor expressive dysphasia • She denied recent neurological symptoms • Treatment: • simvastatin 20 mg per day • bendrofluazide 5 mg per day • carvedilol 25 mg bd • enteric coated aspirin 80 mg per day

  5. Question 1 • What diagnoses do you think are likely?

  6. Question 2 • What investigations would you like to see?

  7. Results - 1 • We arranged: • 24 hour BP monitoring • a full metabolic blood profile • echocardiogram • ABPM – BP monitoring showed a substantial white coat alerting response: • clinic BP average = 176/72 mmHg • day time average = BP 154/72 mmHg • sleep average = 130/62 mmHg

  8. Results - 2 • Sodium 144 (136–145) mmol/L • Potassium 3.6 (3.5–5.1) mmol/L • Urea 7.9 (1.7–8.3) mmol/L • Creatinine 95 (44–80) mmol/L • eGFR 75 mL/min/1.73 m2 • Glucose (Fasting) 6.5 mmol/L • HaemoglobinA1c 8.71 (5.5–7.0 %) • Gamma GT 55 (5–36 IU/L) • Cholesterol 5.5   mmol/L • Triglycerides 0.71  mmol/L • HDL Cholesterol 1.77  mmol/L • LDL (Calculation) 3.43   mmol/L • HDL/Cholesterol ratio 0.32   • Cholesterol/HDL ratio 3.11

  9. Treatment • Patient seen in clinic and commenced on ramipril 5 mg bd, which she did not like, as she said it made her feel lethargic, and she complained her cough was a lot worse after the first two days of treatment • Her doctor reassured her these were unlikely to be due to ramipril as the reaction was too quick, but repeat blood tests showed: • Sodium 140 (136–145) mmol/L • Potassium 4.9 (3.5–5.1) mmol/L • Urea 8.9 (1.7–8.3) mmol/L • Creatinine 123 (44–80) mmol/L • eGFR 57 mL/min/1.73 m2

  10. Question 3 • What do you think is happening?

  11. Progress (3 months later) • The patient had stopped the ramiprilherself • Renal ultrasound was requested and showed bilaterally small kidneys but no suggestion of renal artery stenosis • Her bendrofluazide was stopped and ramiprilrechallenged, this time with no significant increase in creatinine • However the patient maintained that the cough worsened again and refused to continue ramipril

  12. Progress (continued) • She was then commenced on olmesartan/HCTZ combination at doses of 40 mg/12.5 mg • Carvedilolwas replaced with nebivolol 5 mg per day • Her breathing improved and the cough disappeared • On direct questioning she admitted she had not taken her medication regularly as she found the evening dose hard to remember and often omitted it • She took her medication regularly only for the few days before each visit to her doctor

  13. Outcome • Her repeat blood tests after 6 months were better: • Urea 8.2 (1.7–8.3) mmol/L • Creatinine 99 (44–80) mmol/L • eGFR 72 mL/min/1.73 m2 • Glucose (Fasting) 5.5 mmol/L • HaemoglobinA1c 7.1 (5.5–7.0 %) • Repeat ABPM showed: • Day time average BP = 146/74 mmHg, Sleep average = 134/72 mmHg • Her breathing had improved and she had recommenced her regular Pilates classes

More Related