Hakeem A, Beg MS, Ansari S, Javed S, Nazim H, Bharri H, Ali S.
High output heart failure: Case report and review.
Pak J Cardiol Jan ;14(2):69-79.

A 45 year old woman, mother of six, presented with a 6 month history of dizziness, palpitations, fatigue, weakness and shortness of breath on exertion and chest pain for 2 months. She denied any history of associated nausea and vomiting. No history of paresthesia, paralysis or ataxia. Over the past 6-8 weeks, she had become increasingly short of breath, initially only on exertion, and now even at rest, also admitting to have paroxysmal nocturnal dyspnea (PND). She also complained of chest pain on exertion, the pain being retro-sternal, diffuse and radiating to the neck and the left shoulder. She has no other comorbids and no coronary artery disease (CAD) risk factors. The past medical history was essentially unremarkable. She was a mother of 6 children, the youngest being 8 years old. She had no menstrual or gynecological issues, her cycles being quite regular with no dysmenorrhea. The review of systems was unremarkable with no history of bleeding or substantial weight loss. On examination she was afebrile, but tachypneic 30 breaths/minute, and her blood pressure 110/65. She had bounding pulses, throughout however no rhythm disturbances on palpation of her pulses. Her Jugular venous pulse (JVP) was raised to the level that the upper extent coult not be ascertained behind the ear. There was no pedal or sacral edema. The precordium was hyperdynamic with a left parasternal heave, apex beat was a pan systolic murmur, best heard at the left parasternal (tricuspid area), being a grade IV. The liver was palpable 2 finger breadths below the costal margin. Continued..

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