Female patient, aged 57, retired, non-smoking, presents dyspnea on exertion, at minimal effort, chronic severe fatigue, daytime sleepiness, insomnia, broken sleep associated with snoring and apneas, nocturia (2-3 times/night), morning headaches and xerostomia, periodic pain in the periumbilical region.
From history: juvenile obesity (100 kg), hypertensive since the age of 50, presents sleep disturbances and noisy snoring for over 10 years. The physical examination reveals dry skin, mild inferior limbs edema, acrocyanosis (lips, legs), obesity with the BMI = 47 kg/m2 (m=118 kg, h=154 cm), neck girth = 43 cm, abdominal circumference = 140 cm, umbilical hernia 3x4 cm, free nasal breathing, diminished vesicular sounds, stable hemodynamics (HR= 68/min; BP= 130/80 mmHg), Mallampati score III and17 points on the Epworth Sleepiness Scale.
Chest X-ray was normal, ECG revealed signs of right ventricular strain. The EcoCG revealed slight dilation of both atria (up to 56 mm) with the left ventricle of normal dimensions and preserved ejection fraction (50%), severe right ventricle (RV) dilatation (46 mm) and severe pulmonary hypertension (pulmonary artery systolic pressure 80 mm Hg). SpO2 at rest is 95%. Spirometric and blood gazes values are as follows FEV1-81%; FVC-80%; FEV1/FVC-109%, pH 7,43; PaO2 96 mm Hg; PaCO2 44 mm Hg.
Considering the anamnestic data and the physical examination, which are the probable causes of pulmonary hypertension?
What tests do you suggest for confirmation?
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