86-Year-Old Man With Atrial Fibrillation and Dyspnea on Exertion

Abstract

dicine, te ester, o t in ne, , MN A n 86-year-old man with a history of atrial fibrillation (AF) and lower extremity venous stasis ulcers presented to our primary care clinic to establish care. He had dyspnea on exertion that had worsened from baseline limiting his capacity to perform basic activities of daily living including getting dressed. He also had progressive lower extremity swelling for several years and had received ongoing treatment of his venous stasis ulcers from a local vascular surgeon. The patient was taking metoprolol tartrate, 25 mg twice a day, for symptomatic AF diagnosed at an outside institution. His other medications included fish oil and aspirin, 325 mg daily. He reported no nonsteroidal antiinflammatory drug use or excessive salt intake. He had not experienced any cough, sputumproduction, angina, syncope, presyncope, paroxysmal nocturnal dyspnea, orthopnea, or sleep apnea and did not use tobacco or alcohol. On examination, thepatientwas able to speak in full sentences but with difficulty. His blood pressure was 135/89 mm Hg, pulse rate was 93 beats/min, respiratory rate was 18 breaths/min, and oxygen saturation was 97% while breathing room air. His body mass index was 26 kg/m. Cardiovascular examination revealed an irregularly irregular rhythm, normal S1 and S2, and no murmurs, rubs, gallops, or heaves. The point of maximal impulse was enlarged and laterally displaced. There was mild jugular venous distention with a jugular venous pressure of 9 cm and normal waveforms. On pulmonary examination, bibasilar crackles without wheeze were noted. Abdominal examination findings were normal. Examination of the lower extremities revealed 3þ pitting edema involving both knees and healing venous stasis ulcers.