On physical examination: mucous membranes were bluish, CRT - normal; auscultation - slow heart rate (30 bpm), frequent S4 sounds unrelated to the S1 and S2 sounds, a grade 3/6 systolic murmur with a PMI over the left apex and a grade 2-3/6 systolic murmur with a PMI over the right mid heart region; femoral pulses were strong; auscultation - marked inspiratory crackles detected bilaterally over all lung fields.