Abstract
A 46-year-old Dominican woman was transferred to this hospital for chest pain and dyspnea for 1 week. The patient recently lapsed on her outpatient medications, including amiloride, digoxin, furosemide, metoprolol, spironolactone, and warfarin. The patient had a 25-year history of rheumatic heart disease and underwent prosthetic mitral valve replacement 12 years earlier. On presentation, the patient was found to have a pulse of 80 beats/min while in atrial fibrillation. The physical examination was notable for a 4/6 holosytolic murmur at the left lower sternal border, a loud diastolic rumble at the right upper sternal border, and distended neck veins.
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