A Missed Connection

A CLINICAL PROBLEM-SOLVING article by Prashant Bhave from Northwestern University, Chicago.
A 63-year-old woman presented to the emergency department with edema and red discoloration of the skin of her legs. The edema had first appeared almost 2 years earlier but had worsened markedly within the past week and now extended to her midabdomen. She was able to walk about half a block before stopping to catch her breath. She also reported orthopnea, paroxysmal nocturnal dyspnea, and occasional sharp chest pains while walking. She noted that she had gained weight and had mild leg pain but did not have fevers, chills, or night sweats.
The patient was born in El Salvador and immigrated to the United States when she was 45 years of age. She had a remote history of tuberculosis but did not recall any details of the treatment for it.
A history of tuberculosis could put this patient at risk for constrictive pericarditis. In addition, histoplasmosis, which is also seen in Central America, can cause constrictive pericarditis, as well as fibrosing mediastinitis; either condition could raise cardiac filling pressures.  Because the patient lived in Central America for most of her life, she is also at risk for Chagas' disease. (206 words / 82 sec = 150 wpm) [Original Article]

高拍出性心不全の鑑別診断がポイントです。貧血、甲状腺機能亢進症、脚気、SIRSの他に隠されたつながり、シャント（A-V fistula, Bony shunt, Cardiac shunt）の想起が必要です。