A 67-year-old female with a history of coronary artery disease, hypertension and diabetes underwent four-vessel coronary artery bypass grafting four months prior to presentation. Recovery from surgery was uncomplicated and uneventful. Three weeks prior to admission she began to develop progressive dyspnea, lower extremity edema and abdominal discomfort. She complained of decreased exercise tolerance, orthopnea and paroxysmal nocturnal dyspnea. Rosiglitazone was thought be contributing to her progressive edema; however, discontinuation of this medication did not result in resolution of her symptoms. The patient denied chest pain, palpitations or syncope. Physical examination revealed the heart rate to be 72 and regular, blood pressure of 152/80 with 10 mm Hg pulsus paradoxicus. The JVP was elevated to the angle of the jaw with a prominent y descent. Respiratory rate was 24 and elevated to 30 while in the supine position. Lungs were clear to auscultation in the anterior fields, inspiratory and expiratory crackles were present in the lower half of the posterior fields. Cardiac examination revealed distant heart sounds, normal S1 and S2, III/VI systolic murmur most prominent at the left sternal border. Abdominal examination revealed a tense abdomen with normal bowel sounds. Hepatosplenomegaly could not be appreciated. Lower extremities were remarkable for prominent pitting edema. Femoral, popliteal and dorsalis pedis pulses were symmetric. An echocardiogram with respirometer was performed with typical Doppler findings of constriction and moderate tricuspid regurgitation. No pericardial effusion or thickened pericardium was appreciated.
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