Osler Round 4 - 95/F with progressive lower limb swelling

The clinical case

Jajja Dembe, a 95-year-old woman, was brought in by a hired caretaker with complaints of progressive swelling of the legs and abdomen for three weeks, a dry cough worsening at night and when lying flat, and shortness of breath on minimal exertion. She experiences sudden palpitations when startled by loud noises. A vague history of unmanaged hypertension diagnosed five years ago during a community outreach was reported. No history of tobacco or alcohol use. On examination, she is sick, frail, anxious, and afebrile (36.8°C). She has severe bilateral pitting edema up to the thighs and lower abdominal wall. Mild to moderate conjunctival pallor. Not jaundiced, not dehydrated. In the Cardiovascular examination , BP 178/68 mmHg, Pulse 55 bpm (weak and completely irregular). S1 and S2 present, no murmurs. SpO2 is 85% on room air. Per Abdomen: Distended with a positive fluid thrill. Smooth, firm, and tender liver palpable 4 cm below the costal margin. Respiratory rate of 21 breaths per minute. Lung fields are clear to percussion and auscultation bilaterally.