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Section Edition: Alfredo José Mansur (ajmansur@incor.usp.br) Associated Editors: Desidério Favarato (dclfavarato@incor.usp.br) Vera Demarchi Aiello (anpvera@incor.usp.br) Woman with 50 years of age, born in Pernambuco, coming from São Paulo, sought medical assistance due to dyspnea caused by minor stress. Four months ago, the patient presented signs of dyspnea caused by moderate effort, which 2 month ago progressed to minimum effortand orthopnea. The patient also presented edema on lower limbs. She sought medical assistance, was diagnosed with heart failure and was admitted for treatment. The patient knew she had hypothyroidism for years. During admission, the patient underwent thoracocentesis to drain pleural effusion. The biochemal analysis of the pleural liquid (6 Dec 2007) revealed lactate dehydrogenase (LDH) (pleural effusion/serum) 104/216 = 0.48; protein (pleural effusion/serum) 2.8/6.2 = 0.45; albumin gradient = 1.5. The patient was discharged with prescription of 80 mg of Furosemide, 50 mg of Spironolactone, 75 mg of Captopril, 100 μg of levotiroxin on a daily basis, and 0.25 mg of Digoxin every other day. Her dyspnea showed some improvement, however, some days later the dyspnea worsened again upon effort levels below the usual ones. The patient sought medical assistance in this Hospital. Physical examination (9 Jan 2008) revealed eupneic patient, with increased jugular venous pressure, heart rate at 100 bpm and blood pressure 90 / 80 mm Hg. Lung examination revealed a decreased vesicular murmur on the right hemithorax middle third and abolition on the lower third of both hemithoraxes. Cardiac semiology revealed 4th heart sound, with no murmurs or pericardial friction rub. Her abdomen was painful to percussion in right hyponchondrium region. Her liver was palpated at 10 cm from the right coastal edge; there was edema +++/4+ on lower limbs. Chest radiography (9 Jan 2008) revealed a huge bilateral pleural effusion.

Case 5: 50-year-old woman with restrictive cardiomyopathy, renal failure and proteinuria.