Mr. C is an 85-year-old male referred in 2017 for a second opinion with cardiology for "episodic whiteouts for a few years" leading to frequent emergency department visits and hospital admissions. His episodic "whiteout" symptoms are further clarified as a combination of dizziness, fatigue, lightheadedness, exhaustion that prevents him from partaking of any physical activity, and essentially requires him to lie down.

CV comorbidities: Non-ischemic cardiomyopathy, congestive heart failure, atrial fibrillation
Non-CV comorbidities: chronic kidney disease stage 3/4, moderate-severe chronic obstructive pulmonary disease, h/o non-Hodgkin's lymphoma, and neck cancer that necessitated the placement of a gastrostomy tube which is the sole access for all nutritional intake.

Review of Systems: No chest pain, no complaints of palpitation, no syncope.

Physical Exam: He is thin. His pulse is 80 bpm, blood pressure is 74/30 mmHg, and body-mass-index of 23. Heart rate is irregularly irregular without murmurs, lungs are clear to auscultation, and neurologic exam is normal.

Tests: Electrocardiogram: Atrial fibrillation, rate 75-80 bpm. Echocardiogram: ejection fraction - 40%, no significant valvular disease.

Medications: Spironolactone (25 mg), carvedilol (25 mg), amiodarone (200 mg), aspirin (81 mg), losartan (50 mg), warfarin (as directed), furosemide (40 mg), ferrous sulfate (325 mg), levothyroxine (88 mcg), montelukast (10 mg), allopurinol (300 mg), ipratropium-albuterol (4 puffs), vitamin D3/calcium supplements (1 tablet daily), vitamin E (400 IU daily), Fish Oil (2 tablets daily).

Total Number Prescribed Medications: 12

Number Prescribed Cardiovascular Medications: 7

References

1. Gorodeski EZ, Goyal P, Hummel SL, et al. Domain management approach to heart failure in the geriatric patient: present and future. J Am Coll Cardiol 2018;71:1921–36.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias, Statins, Acute Heart Failure

Keywords: Geriatrics, Heart Failure, Dizziness, Warfarin, Atrial Fibrillation, Spironolactone, Furosemide, Heart Rate, Losartan, Amiodarone, Allopurinol, Thyroxine, Calcium, Blood Pressure

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