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Cairo University – Faculty of Medicine
Cardiology Department
Examination of the MD
Degree in Cardiology
November 26, 2001.
Paper III. (Commentary)
Time: 3 hours
- A
60 year-old man was initially
hospitalized because of hypertensive encephalopathy. He has been well until one
month before admission when he became progressively weak and dyspnoeic. Weight
loss of
10 kg was noticed. Laboratory
studies as an outpatient revealed: serum creatinin kinase
612 U/L, serum aldolase
18 U/L (normally
1-6
U/L) and TSH
12 μU/mL. Levothyroxine,
frusemide and prednisone were administered.
- On admission, the blood pressure was
140/80.
There was a grade
2/6
apical systolic murmur, crackles at both lung bases and mild peripheral edema.
Muscle strength was
3/5
in the proximal muscles and was normal in the distal muscles. The skin of the
forehead, perioral area and fingers was slightly tight with periungual erythema
of the finger tips. The patient could not rise from a chair or raise either leg
off the bed. The deep tendon reflexes were normal.
- ECG revealed complete right bundle branch block
and inverted T-waves in leads I and a VL, chest X-ray revealed mild cardiac
enlargement. Laboratory tests revealed a haematocrit f
33.8%, white cell count
7500/cmm, platelet count
432,000/cmm,
ESR
93 mm/hr. Computed tomography
of the abdomen revealed moderate pericardial effusion, small pleural effusion
and fatty changes of the liver. Magnetic resonance image of the proximal thigh
muscles showed intramuscular and perimuscular edema. The patient medications
were adjusted and he was discharged on the
3rd hospital day.
Twelve days later, the patient was readmitted. He
was disoriented with BP
220/140
mmHg, ECG and CXR were unchanged from previous admission. JVP
8 cm, bibasal crackles and
grade
2/6
apical systolic murmur were detected. The deep tendon reflexes were +++ at the
elbows and knees, a jaw jerk and a left sided Babinski reflex elicited. The
margins of the optic discs were blurred. Echocardiography revealed concentric
LVH and an ejection fraction of
30% with akinesis of the
septal, anterior and anterolateral walls. Troponin I was
6.7 ng/Im. Laboratory tests
revealed WBCs
15,
600/cmm, platelet count of
54,000
and a positive D-diameter test. Urinalysis revealed mild proteinuria, numerous
bacteria,
1020 white cells and many
red cells per low power field. Nitroglycerin was given IV with prompt control of
BP.
During the subsequent hospital days, the serum
cretonne rose progressively to
3 mg/dl and blood urea nitrogen
to
90 mg/dl. Abdominal MRI shows
that the right kidney was
10.1 cm long and the left
kidney
11.1 cm long. Computed
tomography revealed discrete non enhancing circular thickening of the aortic
wall but no evidence of intimal flap. A barium swallow revealed multifocal
swallowing disturbance due to lingual and pharyngeal weakness with
nasopharyngeal reflux.
Discuss the diagnosis
and management of the patient.
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