A Woman With AF After Husband’s Death, Grandkids’ Drug Abuse

Asim Kichloo, MD; Nadir Siddiqui, MD; Nazir Lone, MD, MPH; Mohamed A. Mohamed, MD


November 16, 2022

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.


A 72-year-old woman presents with a 3-year history of severe exhaustion and fatigue. She has hypertension, which has been difficult to control despite her use of four antihypertensive medications. She also has poorly controlled type 2 diabetes, which has required increasing doses of insulin. In addition, the patient recently received a diagnosis of paroxysmal atrial fibrillation. She attributes her symptoms and poor control of her medical conditions to ongoing stressors in the past few years, after the death of her husband and substance abuse among her grandchildren.

The patient has a history of difficult intubation for an elective cholecystectomy 5 years ago. She lives with her daughter, who jokingly describes her as snoring "like a drunken sailor." The patient does not have difficulty in initiation of sleep but wakes several times during the night to urinate. She has fatigue and shortness of breath during the day but denies excessive sleepiness or nodding off. Her Epworth Sleepiness Scale score is 9, with a Patient Health Questionnaire-9 score of 8. She has never smoked and does not drink alcohol.


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