An 81-year-old woman with longstanding history of heart disease and atrial fibrillation presents with progressive fatigue and exertional dyspnea over the past 4 months. Prior attempts at cardioversion 10 yrs ago were unsuccessful, and she refused surgery for her heart valve. Two months ago, she began to have trouble speaking, but this has improved. Her high blood pressure had been poorly controlled, so her medications were adjusted 6 months ago. Metoprolol was making her tired. Amlodipine was added, and since then her bp has been ok.
Prior medication: Current medication:
Digoxin Digoxin
Metoprolol 50 mg BID Metoprolol 25 mg
bid/Amlodipine 10 mg
Aspirin 325 mg/day Aspirin 325 mg/day
Metformin Metformin
Vitals:
Afebrile HR
130-160, BP 150/86, RR 28
HEENT:
PERRLA, L facial droop
JVP:
To angle of jaw at 60 degrees
Lung:
Bilateral rales in the lower 1/3rd
Cor:
rapid irregular S1S2S3, PMI in
anterior axillary line, 3/6 holosystolic apical
murmur radiating to the axilla
Abd:
Liver span 16cm
Ext:
Cool, 3+edema bilaterally
An
echocardiogram showed severe left atrial enlargement, moderate to severe mitral
regurgitation and an LVEF of 40%