case continues: A
55 year old white male with a history of hypertension for
15 years comes for a second opinion. He indicates that
his blood pressure always runs about 100 mm Hg diastolic.
He also tells you he has a history of gout in his left
knee. He denies any shortness of breath, chest pain, or
edema, but does admit to nocturia about twice nightly. He
denied taking medication presently.
Physical Examination:
- bp 180/100 with Pulse 60 regular,
supine and standing, both arms.
- Fundi: AV nicking and arteriolar
narrowing bilaterally
- ENT: marked parotid gland
enlargement
- Neck: left carotid bruit
- Chest: increased AP diameter,
decreased breath sounds throughout
- CVS: without gallop or rub. Gr
II/IV SEM at LLSB, increased A2
- ABD: moderately obese, Bowel
sounds normal. No masses, tenderness, or
bruits. Liver span 12 cm. Femoral pulses
decreased with left femoral bruit.
- EXT: without edema or cyanosis.
Marked palmar erythema and clubbing.
Markedly diminished lower extremity
pulses.
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Initial Laboratory
Values:
- BUN 45, Creatinine 4, Na 142, K
4.6, Cl 99, CO2
244, Glucose 210. Cholesterol 280, Uric
Acid 10.3, Triglycerides 310, Ca 7.8, PO4
6.5.
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He was started on 50 mg
hydrochlorothiazide (HCTZ, Esidrix, HydroDIURIL)/75 mg
triamterene (Dyrenium). He returned 2 weeks later. BP now
168/100. BUN 60, Creatinine 6.2, K 6.8.
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