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A 75 year old
man presents to your office for an unscheduled visit at
the behest of his wife. She tells you that she is concerned
about her husband's health. You review his medical record
and notice that the patient’s only other visit occurred
more than 3 years ago. At that time, his blood pressure
was 163/110 and an EKG taken at the time of the visit indicated
left ventricular hypertrophy. You then recommended serum
chemistries and a surface echocardiogram. However, the
patient never obtained these tests. Today, his wife tells
you that "he smokes like a chimney", and further
that "he can barely get around the house anymore without
getting light-headed." The patient complains that "she
won't leave me alone, is always nagging me about my heart." Because
of worsening arthritis, the patient tells you that he has
been "eating ibuprofen like candy."
On physical
examination, the patient's vital signs are as follows:
Blood
pressure: 175/112 with no orthostatic changes
Heart rate: 85/min
Respiratory rate: 24/min
Temperature: 37.2C
The remainder
of the physical examination reveals no jugular venous distension;
his cardiac examination is significant for a laterally
displaced PMI; the neck veins are flat. The pulmonary examination
is significant for increased expiratory phase and scattered
expiratory wheezes. His lower extremities show no edema
bilaterally. The patient agrees to undergo a repeat electrocardiogram
and serum chemistries.
The electrocardiogram
is shown below:
The serum
chemistries and complete blood count are as follows:
Sodium
141 meq/L
Potassium 4.9 meq/L
Chloride 108 meq/L
Bicarbonate 18 meq/L
BUN 27 mg/dL
Creatinine 3.2 mg/dL
Glucose 154 mg/dL
White cell count 12100/µL
Hemoglobin 10.1 g/dL
Hematocrit 31%
Platelet count 249,000/µL
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