Welcome to Case Presentation

Presenter-Dr. Ashiqur Rahman khan MD 3rd Part Student Moderator-Dr.A.K.M.Monwarul Islam Registrar, Department of Cardiology. NICVD, Dhaka.

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

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.

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 disappeared after 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.

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 palpitation and dry cough which had no diurnal or seasonal variation. On quarry she gave history of generalized weakness and fatigue for which her activities of daily living was markedly impaired.

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 chronic liver disease.

History of Past Illness

She gave H/o pulmonary TB 19 years back and she took medications for 7 months.

Treatment History
Tab. Frusemide. Tab. Spironolactone.

Family History
All the family members are now in good health.

Personal History
She was nonsmoker and non alcoholic. She had no H/o illicit exposure and blood transfution. She had incomplete immunization history.

Menstrual History
Menarche at the age of 13 years. Amenorrhoea for 4 years.

Socio-economic History
Lower socio economic group.

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

General Examination
JVP: Raised 8 cm from sternal angle. There was prominent Y descent . Pulse: 104/min, small volume, symmetrical on both sides, irregularly irregular in rhythm & normal in character. No radio radial or radio femoral delay. Pulsus deficit : 26/min BP: 90/70 mm of Hg Respiratory rate: 18/min. Temperature : normal

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

Systemic Examination-Cond.
1st & 2nd heart sounds were audible and soft in intensity. Pericardial knock was present. There was no other added sounds

Systemic examination-Cont..
Abdomen: Inspection: Abdomen was distended, flanks were full. Umbilicus was everted. Palpation : Liver- Palpable, 6 cm from the right costal 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

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.

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 this period of her illness she lost 50% of her previous body weight & developed fatigue with normal activities. She gave no H/o chest pain, haemoptysis, haematemesis and melaena, fever, joint pain, syncope.

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 was raised 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 bilateral varicose veins in both lower limbs.

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 were soft. Pericardial knock was present. Abdominal examination revealed hepatosplenomegaly with ascites. Respiratory examination revealed evidence of right sided pleural effusion.

Provisional Diagnosis
Chronic Constrictive Pericarditis. Atrial fibrillation. Right sided pleural effusion.

Differential Diagnosis
Restrictive cardiomyopathy.
Chronic liver disease

D/D

Points in favour

Points aginst

Restrictive cardiomyopathy

History: Generalized swelling Dyspnoea Palpitations Examination: Prominent y descent Prominent S3

Oedema developed before the onset of dyspnoea Pericardial knock

Chronic liver disease

Generalized swelling Jaundice Hepatosplenomegaly with ascites

No stigmata of liver disease JVP raised Pericardial knock

Investigations
Complete Blood CountHb-9.9 gm/dl ESR- 25 Total CountW.B.C.- 10,800 Differential CountNeutrophil 68% Lymphocyte 28% Monocyte 2% Eosinophil 2% RBS- 6.1 m.mol/l s. 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

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

ECG

Chest X Ray P/A view

Chest X ray P/A view

Cardiomegaly Dextrocardia Right sided pleural effusion

Chest X ray Lateral view

Curvilinear calcification

Echocardiography

Both atria were enlarged Thick(4mm), bright, echogenic pericardium. Abrupt anterior motion of interventricular septum in diastole. Increase in early diastolic velocity with rapid deceleration large E wave and very small A wave. Exaggerated respiratory variation of mitral valve and tricuspid 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.

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.

Cardiac Catheterization
We have a plan to do cardiac cath. and coronary angiogram.

Confirmed Diagnosis
Chronic Constrictive Pericarditis. Atrial fibrillation. Large right atrial thrombus Right sided basal lung collapse with small pleural effusion

Treatment
Medical treatment : Salt restriction. Diuretics. Warferin. Definitive treatment : Pericardiectomy

Thank You All

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 ventricular pressure trace.