A 36-year-old woman is seen in the office because of dyspnea. She emigrated to the United States several years ago in a group of boat people who escaped from Vietnam. She speaks no English; the history is given by a teenage daughter whose English is limited. The patient complains of shortness of breath and fatigue. She was started on digoxin by a physician in a refugee resettlement camp in Indonesia and has been taking 0.25 mg daily. Examination shows a thin, underdeveloped, undernourished woman, who appears slightly dyspneic at rest. Her pulse is 76 and irregular, blood pressure is 95/65, respirations are 23 per minute, and temperature is normal. The arterial pulse is barely detectable. The neck veins are distended when the patient sits up. There is a prominent diffuse systolic expansion in the left parasternal area, with no discrete apical impulse. The first and second sounds are loud. There is either wide splitting of the second sound or a mitral opening snap. A loud holosystolic murmur is heard diffusely over the precordium and a faint short rumbling diastolic murmur is heard at the apex. The chest roentgenogram shows immense cardiac enlargment, the heart shadow nearly reaching the lateral chest wall on the right side. The lung fields show diffuse increase in vascular markings, with particular prominence of the vascular shadows in the upper lobes. The ECG is shown.

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electrocardiography thorax radiography case report female heart Mitral Valve Insufficiency rheumatic heart disease diagnosis human adult Q wave