Mr. Solomon is a 63-year old gentle man who has been under your care for a variety of medical problems during the past 5 years. He has been treated for two myocardial infarctions, hypertension, non-insulin dependent diabetes and stasis dermatitis of the left leg. He had an aorto-coronary bypass one year ago.

Today he presents in the office with shortness of breath which has been progressive over the past five days. He has, however, experienced episodes of shortness of breath during the past four months, especially when exerting himself. He fatigues easily and has lost "all my energy to do anything." He also complains of anorexia. Last night he awoke suddenly from sleep because "I couldn’t catch my breath" and developed a dry cough. The breathing problem improved when he sat on the edge of his bed for an hour. He generally sleeps with two, sometimes three pillows. He has not experienced chest pain, leg pain or fainting spells.

Examination in the office reveals an undernourished man who appears depressed and older than his stated age. He is unkept and unshaven. His shoes are untied. His breathing is labored and his lips have a blue tinge.

Vital Signs: Blood Pressure 98/82mmHg in the right arm; Heart Rate 110/min; Respiratory Rate 26/min; Temperature 98ºF. Examination of the lungs reveals dullness to percussion in both bases with decreased excursion of the diaphragms. Course rhonchi and moist, inspiratory crackles are heard bilaterally in the lower lung fields.

Examination of the cardiovascular system: Neck veins are prominent and distended to the mandible when the patient is sitting upright. The apical pulse is palpated in the 5ICS, left of the MCL. S3 is palpable at the apex. S1 and S2 are diminished. S3 is heard at the apex. A grade 3/6 holosytolic murmur is heard best at the apex; it radiated to the left axilla.

Examination of the abdomen: The anterior wall is round and soft. The liver edge is palpable and tender. The spleen is not palpable. Examination of the extremities revealed diminished peripheral pulses. There is an irregular pulse. There is pitting edema of both lower extremities.

The patient is hospitalized.

ADMISSION LABORATORY TEST

CBC:

Leukocyte count = 8,4000/mm3 with normal differential count

Hemoglobin 14.6g/dL, Hematocrit 40%

Platelet count 290,000/mm3

Chemistries:

Glucose 112mg/dL (non-fasting); BUN 33mg/dL; Creatinine 1.6mg/dL; Total Bilirubin 1.9gm/dL, Direct Bilirubin 0.3mg/dL; Total Protein 5.8g/dL, Albumin 3.1g/dL; Electrolytes: Sodium 132mEq/L, Chloride 93mEq/L, Potassium 4.0mEq/L, Bicarbonate 23mEq/L; Urine: Specific Gravity 1.032, 1 plus protein, hyaline casts.

Chest X-ray:

"Marked prominence of the pulmonary vascular shadows (bilateral), bilateral pleural effusions, increased haziness and decreased radiolucency of the lung parachyma (bilateral), increased transverse diameter of the heart."