Endgames Picture Quiz

A woman with fatigue, dyspnoea, and orthopnoea

BMJ 2010; 340 doi: http://dx.doi.org/10.1136/bmj.c1277 (Published 25 March 2010) Cite this as: BMJ 2010;340:c1277
  1. Vishal Sharma, senior resident,
  2. Mukul P Agarwal, professor
  1. 1Department of Medicine, University College of Medical Sciences (University of Delhi), Delhi, 110095, India
  1. Correspondence to: V Sharma docvishalsharma{at}gmail.com

    A 55 year old woman presented to the emergency department with a history of generalised fatigue of about four months and breathlessness of one month. She had also experienced shortness of breath when lying flat during the past week. She had no history of chest pain or cough, no relevant medical history, and she was not taking drugs.

    On arrival, her blood pressure was 92/66 mm Hg, her pulse was 67 beats/min, her respiratory rate was 20 breaths/min, and oxygen saturation on air was 94%. On examination, her neck veins were distended and cardiac sounds were muffled. She had coarsening of the facies and the deep tendon reflexes showed delayed relaxation. Her chest radiograph showed an increased cardiothoracic ratio, with the appearance of a globular heart. The pulmonary parenchyma seemed to be normal (figure). Electrocardiography revealed low voltage complexes.

    Chest radiograph showing an increased cardiothoracic ratio, with the appearance of a globular heart

    Questions

    • 1 What is the diagnosis on the basis of the clinical findings, chest radiography, and electrocardiography?

    • 2 What investigation would you perform next?

    • 3 On the basis of the history and physical examination, what is the underlying cause of the problem?

    • 4 What other cardiac manifestations are associated with this disease?

    • 5 How should this patient be managed?

    Answers

    1 What is the diagnosis on the basis of the clinical findings, chest radiography, and electrocardiography?

    Short answer

    The diagnosis is pericardial effusion with features of tamponade.

    Long answer

    The pericardium has two layers, a single cell visceral pericardium and a fibrous parietal pericardium. The pericardium is thought to act as a barrier to infection and to have a mechanical function in restraining the cardiac volume. The space between the two layers is called the pericardial sac. It normally contains around 15-35 ml of serous fluid.1 The fluid is an ultrafiltrate of plasma that lubricates the two layers of pericardium. Abnormal increases in the volume of fluid …

    View Full Text

    Sign in

    Log in through your institution

    Free trial

    Register for a free trial to thebmj.com to receive unlimited access to all content on thebmj.com for 14 days.
    Sign up for a free trial

    Subscribe