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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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