Case: A 69-year-old female presented with palpitations and a history of tiredness and shortness of breath for several weeks. She had a previous history of Raynaud syndrome. She was an ex-smoker. She commented that she had not lost her tan since the previous summer. Her only medication was nifedipine for her Raynaud syndrome.
On examination, she was slim and tanned. Pulse rate was 86 beats per minute and regular. Her blood pressure (BP) was 105/74 mm Hg. Her chest was hyperinflated. The rest of her examination was recorded as normal. A chest X ray showed no evidence of cardiac failure. Electrocardiogram monitoring showed episodes of atrial fibrillation. Her routine biochemistry was as follows: serum sodium, 132 mmol/l (normal range, 135–145 mmol/l); potassium, 5.1 mmol/l (3.4–5 mmmol/l); urea, 8.6 mmol/l (2.5–6.4 mmol/l); and creatinine, 110 mmol/l (65–120 ?mol/l).
She was commenced on digoxin and warfarin. Her breathlessness gradually improved, and she remained in sinus rhythm.The patient was admitted into hospital two weeks after the initial presentation. Her main complaints were increasing lethargy and tiredness, reduced appetite, an episode of fainting, and weight loss. For more info see http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.0020229