A woman with fatigue, dyspnoea, and orthopnoea

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.