Insidious Onset of Fatigue, Dyspnea, and Leg Edema

A 56-year-old woman was admitted to the University of Maryland Hospital, Baltimore, on Aug 30,1981. She had been in good health until one year prior to admission, when she noticed insidious onset of fatigue and dyspnea. Her legs became progressively edematous, pruritic, and hyperpigmented. She also experienced nausea, but there was no history of diarrhea, flushing, or wheezing. Physical examination disclosed a well-developed and wellnourished woman. The blood pressure was 110/70 mm Hg; the pulse was 84 beats per minute and regular. The jugular veins were markedly distended; the cardiac apical impulse was slightly beyond the midclavicular line in the left fifth intercostal space. There was a prominent right ventricular heave. A grade 3/6 holosystolic murmur was heard at the left third and fourth interspace parasternally; the intensity of the murmur increased with inspiration. In addition, there was a grade 3/6 ejection systolic murmur and a diminished second heart sound