Clinical history

Mr. C.P. is 65 year old male who presented to the emergency room with chest tightness and associated dyspnea lasting several hours.There was no accompanying nausea, diaphoresis or palpitations. He had not had previous episodes of chest pain.However,he had been in atrial flutter for the past 5 months and had been experiencing progressively worsening exertional dyspnea associated with non-productive cough and two-pillow orthopnea for the past two months. He had been prescribed oral furosemide with some improvement. His past history was also significant for normocytic anemia, seronegative arthritis and recurrent perineal cellulitis since 1992.

The physical examination was significant for an irregularly irregular pulse of 82, a laterally displaced and enlarged cardiac apex but no third heart sound. The lungs were clear to auscultation. Peripheral pulses were normal. There were no carotid or femoral bruits..

Labs
SMA-7: Normal
Serial CPK: Normal
Hgb: 113
MCV: 81.2
EKG: Atrial flutter, variable block
No ST depression
CXR: Cardiomegaly, venous redistribution, no inerstitial edema
U/A: 15-20 RBC/hpf, several hyaline and granular casts
Protein 0.3 g/L

Questions

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Reference