Case 2:

A 74-year old retired elementary school principal is referred to you for general care after a change in his HMO provider. He has a history of CAD and suffered a large anterior wall infarction eight months ago complicated by acute pulmonary edema requiring mechanical ventilation. He subsequently underwent a PTCA and stenting of the LAD and has had no ischemic symptoms since. The LV ejection fraction was last measured at 25% by echocardiogram done three months ago. There was mild mitral regurgitation noted.

For the past two months he has noted increasing dyspnea on exertion and an eight-pound weight gain. He never complains of chest discomfort, but is only able to walk up one flight of stairs before having to rest. He uses 3 pillows to prop his head up at night and will occasionally wake up in the middle of the night with a dry cough.

His medications include Lisinopril 20mg/day, ASA 325 mg/day, Plavix 75 mg/day, and furosemide 20 mg/day. He has no drug allergies.

BP 110/70   HR 110   RR 20   T 97F

General:   Appears older than stated age, able to complete sentences, comfortable while sitting.

Neck:      JDV=10 cm at 45 o

Lungs:     Few rales at bases

CV:         PMI laterally displaced, S1 S2 regular, soft S3 and 3/6 HSM at apex radiating to axilla.   No rub.

Abd:        Normal

Ext:         1+ Bilateral ankle edema