DR DELBANCO: Mr C is a
75-year-old retired fisherman who came to the United States from the
West Indies more than 10 years ago. He and his wife live in Boston,
Mass, with their daughter, who has been an important source of support
for him. He has Medicare and supplemental commercial insurance.
In 1988, Mr C developed exertional dyspnea and was diagnosed
as having congestive heart failure and chronic obstructive pulmonary
disease (COPD), with a forced expiratory volume in 1 second of
less than 0.5 L. Chest radiographs showed a large cardiac silhouette,
with hyperlucent lung fields and flat diaphragms. Electrocardiogram
results showed poor R-wave progression and were consistent with left
ventricular hypertrophy and left atrial enlargement. Echocardiogram
results showed severe left ventricular dilatation, diffuse hypokinesis,
ejection fraction of less than 0.20, and mild right heart
dilatation, with 3+ mitral regurgitation and 2+ tricuspid
regurgitation. He also had chronic mild renal insufficiency, with a
creatinine level of about 221 µmol/L (2.5 mg/dL), and a history of
gout, with erosive arthritis, nephrolithiasis, and uric acid stones.
There is no known family history of heart disease. Cardiac risk factors
include long-standing mild hypertension and 50 pack-years of cigarette
smoking, ending in 1988.
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