Eighty-nine-year-old woman with fatigue and reduced appetite

An active, independent 89-year-old woman presented to her primary care physician with a 4-month history of fatigue, anorexia, exertional dyspnoea and weight gain. She had no chest pain, orthopnoea, paroxysmal nocturnal dyspnoea, symptoms of infection or blood loss. She had a history of colorectal cancer with a hemicolectomy 10 years prior. She had a dual chamber pacemaker, now in atrial fibrillation on warfarin. On examination her heart rate was 72 bpm, blood pressure 128/70mmHg and peripheral oxygen saturations 97% on air. Her chest was clear, jugular venous pressure was not elevated with only mild peripheral oedema. EKG showed atrial fibrillation with intermittent pacing. Blood tests …