Amanda VP. is a 44-year-old Russian immigrant whom you first meet at family health team where you are completing your core training as a family medicine resident. Amanda presents to the clinic because she’s had a two-week history of fevers, chills, malaise and shortness of breath on exertion. She became particularly concerned earlier today when she experienced a brief episode of left arm weakness that lasted for approximately 5 minutes and then completely resolved. Amanda, one of four children, grew up in the former Soviet Union, in a poor household with her extended family (cousins, aunt and uncle, and grandparents). Amanda VP.’s short stature makes you wonder if she was malnourished as a child and if so, what other effects this may have had on her health. Her past medical history seems unremarkable. She has been hospitalized once when she delivered healthy twin girls twenty years ago. She does recall having been told by her obstetrician that she had a heart murmur. She is married and works as a dental assistant in her husband's office. She smokes one pack of cigarettes daily and has done so for 30 years. She does not drink alcohol. On examination, she looks unwell. She is febrile with a temperature of 38.8 degrees Celsius. Her heart rate is 110 bpm with a BP of 100/65 mmHg. Head and neck examination reveals bilateral conjunctival petechiae. Her JVP is 4 cm above the sternal angle. Her chest is clear. Heart sounds reveal a grade 3/6 pan-systolic murmur best heard at the apex and an S3 with gallop. Her point of maximal impulse is enlarged and palpated in the anterior axillary line. She has mild bilateral pedal edema. Neurological examination, including fundoscopy, is completely normal as is the dermatologic exam. You decide to admit her to hospital, order blood work, a chest X-ray, and an echocardiogram.