Case History / Examination

A 41-year-old female presented to the emergency with a history of dizziness for 6 hours, shortness of breath for 1 day and chest pain and shortness of breath characterized by orthopnea and paroxysmal nocturnal dyspnea for the past 2 weeks. She had been under regular maintenance hemodialysis for end-stage renal disease (ESRD), secondary to systemic hypertension of 17 years, for the past 6 months. An autogenous brachiocephalic arteriovenous fistula (AVF) was created on her left arm 10 months back citing future requirement for hemodialysis. Although renal transplantation had been contemplated, a proper match had not been found. The patient had had her regular scheduled hemodialysis 2 days before her visit to the emergency. There was no history of trauma to the AVF.
At presentation, vital signs included a bradycardia of 46/m, blood pressure of 60/40 mm of Hg, SpO2 of 86% in room air, respiratory rate of 16/m and she was afebrile. She was drowsy, but oriented to time, place and person. No focal neurological deficits were evident and there were no flaps. Heart sounds were muffled and jugular venous distension was obvious. No bruit was appreciated in her native AVF.