Vivian Hayashi MD and Robert Smith MD, Mystery Quiz Section Editors
The patient is a 61 year old man presenting with one month of worsening shortness of breath. The patient has a history of alcoholism and was diagnosed with atrial fibrillation during a hospital admission for detox three years earlier. Warfarin therapy was not begun due to a history of poor medication compliance. One year prior to admission an echocardiogram showed a normal global ejection fraction and mild mitral regurgitation. One month prior to admission, the patient noted the onset of worsening breathlessness and occasional palpitations. He denied hemoptysis, night sweats, sputum production, known exposure to tuberculosis, or changes in weight. Social history was noteworthy for current alcohol abuse and a remote history of IV drug abuse; the patient denies ever smoking. On admission, he was noted to be afebrile with labored respiration, an irregular pulse of 92 beats per minute, blood pressure of 150 systolic, O2 saturation of 93% on room air; chest exam revealed bibasilar rales and extremities were mildly edematous. WBC was 6.8K, hemoglobin 11.7gm, and platelet count 153K. Brain natriuretic peptide level was 630 (ref. range 0-100). Chest radiograph upon admission is shown below:
