A 74-year-old man with bilateral iliac aneurysms had a 20-to 30-year history of hypertension, which was reasonably well controlled by medications. He had suffered two myocardial infarctions 12 and 20 years previously. Three years previously, he had undergone elective repair of an infrarenal abdominal aortic aneurysm with an aortobifemoral prosthetic graft. He had suffered several episodes of urinary tract infection in the 3 to 4 years preceding admission; 5 months before admission he was treated successfully for another urinary tract infection, but residual microscopic hematuria was noted. Results of a cystoscopy were normal, but an intravenous pyelogram demonstrated gross left hydronephrosis with bilateral iliac artery aneurysms. He was admitted for arteriography and operation.The patient had no history of diabetes, hypercholesterolemia, cigarette smoking, or alcohol abuse. Medications included triamterene and hydrochlorothiazide (Dyazide), 1 capsule per day, a-methyldopa, 250 mg t.i.d. orally, and nadolol, 40 mg/day orally.The patient had mild stable angina and 2-to 3-block dyspnea on exertion. He also complained of dysuria, hematuria, and twice-nightly nocturia.Physical examination on admission revealed a welldeveloped man in no distress. His pulse rate was 64 beats/min, and his blood pressure was 140/86 mm Hg without postural change. Carotid pulses were normal, with a right carotid bruit. Examination of the lungs showed bilateral basilar rales. Point of maximal impulse was the sixth intercostal space at the anterior axillary line; S, was constant, S 2 was physiologically split, and S 4 was present. A grade 2/6 apical systolic murmur radiating to the left sternal border was also present. The patient's abdomen was obese with a pulsatile left lower quadrant and no organomegaly. A small, firm prostate was noted, and the extremities showed no edema. Ankle pulses were present except for an absent right posterior tibial pulse.Laboratory studies disclosed the following values: normal electrolyte levels; creatinine, 2.1 mg/dl; blood urea nitrogen, 33 mg/dl; hematocrit, 42%. Chest roentgenogTam showed cardiomegaly and tortuous aorta. Electrocardiogram showed left axis deviation, left atrial abnormality, prominent lateral S waves, possible pulmonary disease, and nonspecific ST-T wave changes. Urinalysis demonstrated proteinuria (4 + ) and 25 to 30 red blood cells per high power field. Urine culture was negative.
Case DiscussionThe patient is an elderly man with a history of longstanding hypertension well controlled on medications who also has symptomatic coronary artery disease characterized by two remote myocardial infarctions