Experts

Analysis: All three episodes are consistent with atrial fibrillation with rapid ventricular response. Key findings:

- Irregularly irregular rhythm with absence of P waves
- Ventricular rate 108-138 bpm during episodes
- Episode duration increasing: 22 min → 34 min → 86 min
- HRV significantly reduced during episodes (23ms vs baseline 45ms)

Recommendation: Current rate control appears insufficient. Consider referral to EP for rhythm control strategy discussion. CHA2DS2-VASc score = 4, anticoagulation appropriately maintained with Eliquis.

Thank you for the referral, Dr. Chen. Given the GI intolerance and declining adherence, I'd recommend:

1. Switch to Metformin ER 1000mg BID — significantly fewer GI side effects with equivalent efficacy. Many patients who can't tolerate IR do well on ER.
2. If ER not tolerated: Consider adding GLP-1 RA (semaglutide) which would address both glycemic control and the weight management benefit.
3. CGM data: The fasting glucose pattern suggests hepatic glucose output as the primary driver — Metformin remains first-line for this.

Happy to see the patient if you'd like a formal endo consult. The Digital Twin data you shared was very helpful.

Findings: Bilateral pleural effusions (small-to-moderate), cardiomegaly with cardiothoracic ratio 0.58, upper lobe pulmonary venous distension, and bilateral perihilar haziness consistent with pulmonary edema.

Impression: Imaging findings consistent with CHF exacerbation. Correlates with the reported 8lb weight gain from wearable data. Recommend diuretic adjustment and close follow-up. No pneumothorax or focal consolidation to suggest infection.