Case Presentation

A 67 year-old Cantonese speaking male was seen at primary careclinic with complaints of dyspnea on exertion and decreasedexercise tolerance. His medical history includes rheumaticheart disease, tricuspid regurgitation, tricuspid repair threemonths ago, mitral regurgitation, mitral valve replacement witha bioprosthetic valve three months ago, atrial fibrillation onanticoagulation therapy, permanent pacemaker implantation,severe pulmonary hypertension, benign prostatic hypertrophy,gastroesophageal reflux disease, and iron deficiency anemia.The patient reports that in the last two weeks, he has beenunable to ambulate more than two blocks limited by shortnessof breath, which represents an acute change. He also complainsof bilateral lower extremity edema. He reports that two weeksafter his mitral valve replacement, his exercise tolerance wasdramatically improved, and he was able to ambulate more thantwo blocks without difficulty.