Chronic lethargy in a 68 yo woman

• Medical history: Hypertension diagnosed 10 yr ago and controlled with three antihypertensives. Atrial fibrillation (AF) rate-controlled with bisoprolol; previous admission to hospital with a fast AF complicated with acute left ventricular failure; cardioversion failed to restore sinus rhythm.


• Surgical history: Appendectomy at the age of 19 yr, left carpal tunnel syndrome surgery 2 yr ago.


• Medications: Bisoprolol 5 mg once/day, ramipril 10 mg once/day, furosemide 40 mg once/day, warfarin 3 mg once/day.


• Allergies: No known drug allergies.


• Family history: Mother had hypothyroidism and a stroke in her 80s. Father died of metastatic colon cancer.


• Social history: She eats a healthy balanced diet, and her only exercise is walking to nearby shops twice a week. She used to work as a receptionist but retired 3 yr ago. She is a nonsmoker and drinks alcohol only occasionally. She has not travelled abroad in the last 3 yr.