56-year-old Xray technician presents with more than a week history of exertional dyspnea and “skipped beats.” He drinks a few cocktails about 3 times/ week. He has put on 8 pounds in 2 weeks and has not slept well for the past month.
PH: hypertension, Type 2 diabetes, psoriasis
Temp 37.2 HR 120-140 BP 174/96 RR 24
JVP: Visible to 8 cm at 45 degrees
Lung: Bibasilsar rales
Cor: Sustained displaced PMI 4 cm to the left of the mid-clavicular line. Variable S1, S2 with mild increased P2, + Parasternal lift, +S3, II/VI systolic murmur at lower sternal border
Abdomen: Liver 14 cm
Extremities: Cool with 2+ pitting edema to the knees
EKG shows atrial fibrillation with a rapid response.