Clinical History.—A boy aged 13 years and 9 months was referred to the University of New Mexico Medical Center because of increasing dyspnea on exertion, shortness of breath, orthopnea, and a 6.4-kg weight gain over a period of four days. He had been experiencing congestive heart failure for at least one year, but came to the hospital because of exacerbation of symptoms.
Physical Examination.—The temperature was 37.3 C; the pulse rate, 112 beats per minute; respiratory rate, 28/min; and blood pressure, 120/70 mm Hg. Bilateral rales were heard. Examination of the heart revealed diffuse hyperactivity, sustained point of maximum intensity in the anterior axillary line with a right ventricular lift, as well as a grade 2/6 holosystolic murmur over the precordium, maximal at the lower left sternal border with radiation to the apex but not the axilla. The liver was down 4 cm. There was 4 + pitting edema