Question: H.J. presented to the ER late one evening complaining of a “racing heartbeat.” She is an overweight, 69-year-old white female, who has been experiencing increasing shortness of breath during the past two months and marked swelling of the ankles and feet during the past three weeks.

H.J. presented to the ER late one evening complaining of a “racing heartbeat.” She is an overweight, 69-year-old white female, who has been experiencing increasing shortness of breath during the past two months and marked swelling of the ankles and feet during the past three weeks. She feels very weak and tired most of the time and has recently been waking up in the middle of the night with severe breathing problems. She has been sleeping with several pillows to keep herself propped up. Five years ago, she suffered a transmural (i.e., through the entire thickness of the ventricular wall), anterior wall (i.e., left ventricle) myocardial infarction. She received two-vessel coronary artery bypass surgery 41 ⁄2 years ago for obstructions in the left anterior descending and left circumflex coronary arteries. Her family history is positive for atherosclerosis as her father died from a heart attack and her mother had several CVAs. She had been a three pack per day smoker for 30 years but quit smoking after her heart attack. She uses alcohol infrequently. She has a nine-year history of hypercholesterolemia. She is allergic to nuts, shellfish, strawberries, and hydralazine. Her medical history also includes diagnoses of osteoarthritis and gout. Her current medications include celecoxib, allopurinol, atorvastatin, and daily aspirin and clopidogrel. The patient is admitted to the hospital for a thorough examination.

Vital Signs BP  125/80 (left arm, sitting);

P  125 and regular;

RR  28 and labored;

T  98.5°F oral;

Weight  215 lb;

Height  58;

patient is appropriately anxious Head, Eyes, Ears, Nose, and Throat

• Funduscopic examination normal
• Pharynx and nares clear
• Tympanic membranes intact Skin
• Pale with cool extremities
• Slightly diaphoretic Neck
• Neck supple with no bruits over carotid arteries
• No thyromegaly or adenopathy
• Positive JVD
• Positive HJR

Lungs •

Bibasilar rales with auscultation • Percussion was resonant throughout

Heart • PMI displaced laterally • Normal S1 and S2 with distinct S3 at apex • No friction rubs or murmurs

Abdomen • Soft to palpation with no bruits or masses • Significant hepatomegaly and tenderness observed with deep palpation

■ Extremities • 2  pitting edema in feet and ankles extending bilaterally to mid-calf region • Cool, sweaty skin • Radial, dorsal pedis and posterior tibial pulses present and moderate in intensity

Neurological • Alert and oriented 3 (to place, person, and time) • Cranial and sensory nerves intact • DTRs 2  and symmetric • Strength is 3/5 throughout

Chest X-Ray • Prominent cardiomegaly • Perihilar shadows consistent with pulmonary edema

ECG • Sinus tachycardia with waveform abnormalities consistent with LVH • Pronounced Q waves consistent with previous myocardial infarction ECHO Cardiomegaly with poor left ventricular wall movement

Radionuclide Imaging EF  39%

Laboratory Blood Test Results See Patient Results

Na  153 meq/L

PaCO2 53 mm Hg

K  3.2 meq/L

PaO2 65 mm Hg (room air)

BUN 50 mg/dL

WBC 5,100/mm3

Cr 2.3 mg/dL

Hct 41%

Glu, fasting 131 mg/dL

Hb 13.7 g/dL

Ca 2 9.3 mg/dL

Plt 220,000/mm3

Mg 2 1.9 mg/dL

Alb 3.5 g/dL

Alk phos 81 IU/L

TSH 1.9 µU/mL

AST 45 IU/L

T4 9.1 µg/dL

pH 7.35