A 64-Year-Old Woman with Fatigue and Dyspnea

AbstractMorning Report is a time-honored tradition where physicians-in-training present cases to their colleagues and clinical experts to collaboratively examine an interesting patient presentation. The Morning Report section seeks to carry on this tradition by presenting a patient's chief concern and story, inviting the reader to develop a differential diagnosis and discover the diagnosis alongside the authors of the case. This report describes the story of a 64-year-old woman with a remote history of rheumatic heart disease who presented with progressive fatigue and exertional dyspnea more than two decades after undergoing aortic- and mitral-valve replacements. Using questions, physical examination, and testing, an illness script for the presentation emerges. As the clinical course progresses, the differential is refined until a final diagnosis is made.