A 75-year-old woman, with a 20 year history of hypertension and angina is presenting with complaints of tiredness and easy fatigue:

• Coarse atrial fibrillation with slow ventricular response (40/min)
• Left ventricular hypertrophy
• Marked ST and T abnormality, consider anterolateral ischemia

The recent onset of tiredness and easy fatigue may be related to the slow ventricular response. This lady is on digoxin, and a beta blocker. The medication should be reassessed. The marked ST and T abnormalities suggest ischemia, rather than changes secondary to left ventricular hypertrophy.