Clinical Note On Clinical Disorders

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Clinical vignette A fifty-two-year-old white male visited his physician because he started experiencing shortness of breath on walking short distances at ground level. He had smoked half a packet of cigarettes daily for 40 years. Physical examination revealed a loud fourth heart sound and a blood pressure of 147/95 mmHg. Chest examination and chest X-ray were unremarkable, and ECG showed left atrial abnormality. The patient had normal serum electrolytes, blood sugar, and kidney function tests. A stress echocardiogram was ordered to exclude potential coronary artery disease (CAD). His resting echocardiography showed an ejection fraction (EF) of 60%, normal septal and posterior wall thickness, and mild diastolic dysfunction [septal early diastolic mitral annular velocity (e’) of 7 cm/s, early diastolic (E-wave) to late diastolic (A-wave) transmitral Doppler flow velocity ratio (E/A) of 1.4, E-wave deceleration time of 210 milliseconds, and E/e’ ratio of 9]. There were no resting segmental wall motion abnormalities suggestive of ischemia. The patient exercised on a treadmill using Bruce protocol for 4 minutes and 43 seconds, and achieved 6.6 metabolic equivalent of task (MET) and maximum heart rate of 148 beats/minute (88% of his maximum age predicted heart rate). At peak exercise, the patient developed severe dyspnea and his blood pressure was 213/90 mmHg. Post exercise echocardiography was acquired within 1 minute of exercise termination with Doppler recordings obtained at
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