Introduction
A 50-year-old postmenopausal woman with no prior comorbidity, was brought to the emergency department with two weeks history of exertional dyspnoea, syncope and generalised weakness. There was no associated chest pain or cough. She had experienced three episodes of syncope characterised by loss of consciousness, each episode lasting for 2–3 mins.
On examination, she was a middle-aged woman with a pulse of 100 beats·min−1, blood pressure of 120/80 mmHg, respiratory rate of 20 breaths·min−1, room air oxygen saturation of 95% and jugular venous pressure within the normal range. Leg veins were prominent with minimal pedal oedema. Respiratory examination revealed an elliptical chest, normal vesicular breathing and occasional wheeze. Cardiovascular examination revealed a right ventricular heave, audible heart sounds with a systolic murmur audible at the tricuspid area and palpable peripheral pulses.
The chest radiograph (CXR) from a local hospital is shown in figure 1.
Chest radiograph.
Task 1
What does the chest radiograph demonstrate?
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a. Left sided pleural effusion
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b. Cardiomegaly
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c. Lung infiltrates
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d. Bilateral hilar prominence
Answer 1
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b. Cardiomegaly
An electrocardiogram (EKG) revealed right ventricular strain with no evidence of an acute coronary episode. Initial investigations at our hospital showed a haemoglobin level of 14.9 mg·dL−1 (11.5–13.8 mg·dL−1), total white cell count of 13.2×109 cells·L−1 (4.0–10.0×109 cells·L−1) and platelets of 174×109 cells·L−1 (150–400×109 cells·L−1). Arterial blood gases showed pH 7.53, oxygen tension 65.9, carbon dioxide tension 27.2, HCO3- 22.7 …
