case:chronic constrictive pericarditis.nicvd

7/27/2019 case:Chronic Constrictive Pericarditis.nicvd

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Welcome

toCase Presentation

Presenter-Dr. Ashiqur Rahman khan

MD 3rd Part Student

Moderator-Dr.A.K.M.Monwarul Islam

Registrar, Department of Cardiology.NICVD, Dhaka.


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Particulars of the Patient

Name : Y

Age: 33 Years

Sex: Female

Religion: Islam

Marital Status: Married

Address: vandaripur, Pirojpur

Date of Admission: 02/10/2010


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Chief Complaints

Generalized swelling of the body for 8 years but

increased for 1week.

Shortness of breath for 2 years.

Weight loss for the same duration.


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History of Present Illness

According to the statement of the patient she

was reasonably well 8 years back. Since then

she developed swelling of the abdomen which

was initially mild, intermittent and disappearedafter taking some medications. Later on

abdominal distention was persistent and was

associated with vague abdominal discomfort.Several months later she noticed swelling of

both legs along with facial puffiness.


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History of Present Illness- cond.

The patient gave history of shortness of

breath for the last 2 years which occurred

with moderate exertion but not on lying

flat. She also gave H/o occasional palpitationand dry cough which had no diurnal or

seasonal variation. On quarry she gave history

of generalized weakness and fatigue for whichher activities of daily living was markedly

impaired.


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History of Present Illness-cond.

During this period of her illness she developed

gradual loss of her appetite and lost about 50%

of her previous body weight.

Her bowel and bladder habit was normal. She gave no H/o chest pain, wheezing,

coughing out of blood, prolong fever, joint pain,

rash, loss of consciousness, weakness of one

side of the body and passage of black tarry

stool. For this illness she got herself admitted

several times in different hospitals of Dhaka and

was diagnosed and treated as a case of chronicliver disease.


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History of Past Illness

She gave H/o pulmonary TB 19 years back and

she took medications for 7 months.


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Treatment History

Tab. Frusemide.

Tab. Spironolactone.


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Family History

All the family members are now in good health.


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Personal History

She was nonsmoker and non alcoholic.

She had no H/o illicit exposure and blood

transfution.

She had incomplete immunization history.


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Menstrual History

Menarche at the age of 13 years.

Amenorrhoea for 4 years.


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Socio-economic History

Lower socio economic group.


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General Examination

Appearance: Ill looking

Body built: Below Average

Co-operative

Decubitus:

Anaemia : Mild.

Jaundice: Mild

Cyanosis: Absent.

Clubbing: Absent.

Oedema: Absent.

Lymph nodes: Not palpable

Thyroid gland not enlarged

Varicose veins: Present


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General Examination

JVP: Raised 8 cm from sternal angle. There wasprominent Y descent .

Pulse: 104/min, small volume, symmetrical on both

sides, irregularly irregular in rhythm & normal incharacter. No radio radial or radio femoral delay.

Pulsus deficit : 26/min

BP: 90/70 mm of Hg

Respiratory rate: 18/min. Temperature : normal


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Systemic Examination- Precordium

Shape of the chest : Normal

No visible pulsation.

Apex beat at the left 5th intercostal space 6 cm

from the midline. It was normal in character. Left parasternal heave and epigastric pulsation :

Absent.

There was no palpable P2.

Thrill : Absent


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Systemic Examination-Cond.

1st & 2nd heart sounds were audible and soft inintensity.

Pericardial knock was present.

There was no other added sounds


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Systemic examination-Cont..

Abdomen:

Inspection: Abdomen was distended, flanks

were full. Umbilicus was everted.

Palpation : Liver- Palpable, 6 cm from the rightcostal margin along the mid clavicular line,

tender, soft in consistency, surface smooth,

margin rounded. Upper border of liver dullness

at the right 5th ICS in the mid clavicular line.

Spleen was just palpable.

Percussion: fluid thrill was present.

Auscultation : there was no bruit


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Systemic Examination-Cond.

Respiratory system:

percussion note was dull at right lung base.

Breath sound was vesicular & decreased on

right side from 7th space downwards in the

mid axillary line.

vocal resonance was also diminished on

right side.

Other systemic examination-No abnormality.


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Salient Features

Mrs. Y, 33 years old Muslim, married, nondiabetic lady

hailing from Pirojpur got her self admitted on 2nd

October, 2010 with the complaints of generalized

swelling of the body for 8 years which was worsen for

the last one week and was associated with vague

abdominal discomfort. For the last 2 years she gave

history of dyspnoea on exertion which was NYHA Grade

2, having no H/o orthopnoea. It was associated with

intermittent palpitations and dry cough. During thisperiod of her illness she lost 50% of her previous bodyweight & developed fatigue with normal activities. Shegave no H/o chest pain, haemoptysis, haematemesis

and melaena, fever, joint pain, syncope.


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Salient Features Cond.

On Examination she was ill looking with average

body built and below average nutritional status,

mildly anaemic and icteric. Oedema was absent.

There was no cyanosis & clubbing. JVP wasraised with prominent y descent. Pulse-104/min,

symmetrical, irregularly irregular, small volume,

normal in character and pulsus deficit was

26/min. BP-90/70mmHg. There was bilateralvaricose veins in both lower limbs.


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Salient Features Cond.

Precordial examination revealed apex beat was

left 5th ICS 6 cm from the midline, normal in

character. Parasternal heave, palpable P2 &

thrill were absent.1st

and 2nd

heart sounds weresoft. Pericardial knock was present.

Abdominal examination revealed

hepatosplenomegaly with ascites.

Respiratory examination revealed evidence of

right sided pleural effusion.


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Provisional Diagnosis

Chronic Constrictive Pericarditis.

Atrial fibrillation.

Right sided pleural effusion.


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Differential Diagnosis

Restrictive cardiomyopathy.

Chronic liver disease


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D/D Points in favour Points aginst

Restrictive

cardiomyopathy

Chronic liver disease

History:

Generalized swelling

Dyspnoea

Palpitations

Examination:

Prominent y descent

Prominent S3

Generalized swellingJaundice

Hepatosplenomegaly

with ascites

Oedema developed

before the onset of

dyspnoea

Pericardial knock

No stigmata of liverdisease

JVP raised

Pericardial knock


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Investigations

Complete Blood Count-Hb-9.9 gm/dl

ESR- 25

Total Count-

W.B.C.- 10,800

Differential Count-Neutrophil 68%

Lymphocyte 28%

Monocyte 2%

Eosinophil 2%

RBS- 6.1 m.mol/ls. Electrolytes

Na- 133 meq/l

k-4.3 meq/l

S.Creatinine 0.9 mg/dl, S.Bilirubin-1.4mg/dl,SGPT-31U/L, SGOT-29U/L


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Investigation-cont..

Urine R/M/E: pus cell 1-2/HPF, Albumin trace.

S. albumin: 3.6 gm/dl, S. total protein: 6.8gm/dl

ProthombinTime: 15.8 sec, INR:1.28

HBsAg & AntiHCV: Negative MT test: Negative.

Sputum for AFB: Negative.

USG of the Abdomen-Congestive Hepatoslenomegaly

with moderate ascities. Upper GIT endoscopy: Normal


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ECG


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Chest X Ray P/A view


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Chest X ray P/A view

Cardiomegaly

Dextrocardia

Right sided pleural effusion


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Chest X ray Lateral view

Curvilinear calcification


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Echocardiography

Both atria were enlarged Thick(4mm), bright, echogenic pericardium.

Abrupt anterior motion of interventricular septum indiastole.

Increase in early diastolic velocity with rapid deceleration large E wave and very small A wave.

Exaggerated respiratory variation of mitral valve andtricuspid valve inflow.

MV E amplitude decreases by >25% on inspiration and

TV E wave decreases by >25% on expiration. Inferior venacava is dilated without inspiratory reduction

in diameter. Hepatic veins are also dilated.

Diastolic collapse of RV not seen.

Large RA thrombus is seen.


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CT of Chest(noncotrast)

Heart & pericardium: Heart & mediastinum is

shifted to right. Pericardial thickening &

calcification is noted.

Lung & pleura: mixed density lesion with fibrosis& evidence of cicatrisation collapse is seen in rt

lower lobe in posterior basal segment.

Right sided small pleural effusion with pleural

thickenig is seen.


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Cardiac Catheterization

We have a plan to do cardiac cath. and coronary

angiogram.


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Confirmed Diagnosis

Chronic Constrictive Pericarditis.

Atrial fibrillation.

Large right atrial thrombus

Right sided basal lung collapse with smallpleural effusion


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Treatment

Medical treatment : Salt restriction.

Diuretics.

Warferin.

Definitive treatment : Pericardiectomy


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Thank You All


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Cardiac Catheterization

End diastolic pressure raised and equal in all

chambers.

Diastolic filling pattern is a reflection of the dip

and plateau pattern in left and right ventricularpressure trace.


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case:chronic constrictive pericarditis.nicvd

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