Case Presentation

Class 2014
Block A
 M.M. 28 YEAR OLD FEMALE
Common law wife with 2 children
High School Graduate
Unemployed
Lives in BrgyTatalon, Quezon City
 CHIEF COMPLAINT:

Difficulty Of Breathing
 HISTORY OF PRESENT ILLNESS
2 years PTA -- (+) easy fatigability
(+) cough
(+) shortness of breath
(+) exertionaldyspnea
(-) chest pain
Consult Local clinic:
A> Bronchial Asthma
P>Salbutamol tab
7 months PTA -- (+) gradual abdominal enlargement
(+) bipedal edema
Consult Local clinic:
Given Furosemide 40mg/tab
 HISTORY OF PRESENT ILLNESS
4 months PTA --(+) progressive abdominal
enlargement, bipedal edema
(+) exertionaldyspnea
(+) increasing abdominal girth
(+) jaundice
 HISTORY OF PRESENT ILLNESS
1 week PTA -- (+) increased severity of bipedal
edema
(+) dyspnea at rest
(-) consult, opted to continue
Furosemide
(+) cough with yellow sputum production
(+) low grade fever

Day of Admission -- (+) increased severity of

difficulty of breathing
Prompted consult
 Review Of Systems
CONSTITUTIONAL PULMONARY ENDOCRINOLOGIC
(-) Fever (+) cough
(-) anorexia (-) hemoptysis (-) polyuria
(-) weight loss (-) polydipsia
(-) heat intolerance
CARDIAC GENITO-URINARY (-) tremors
(+) exertionaldyspnea (-) hematuria
(+) easy fatigability (-) oliguria
(-) palpitations (-) dysuria GASTROINTESTINAL
(-) chest pain
(+) PND/ orthopnea (-) abdominal pain
(-) cyanosis (-) jaundice
(+) bipedal edema (-) constipation
(-) intermittent claudication HEMATOLOGIC (-) diarrhea
NEUROLOGIC (-) bleeding (-) melena
(-) syncope (-) easy bruisability (-) hematochezia
(-) dizziness (-) hematoma
(-) behavioral changes (-) pallor
(-) hemiparesis
 PAST MEDICAL HISTORY
• PTB- inadequately treated 2007
• No DM
• No Hypertension
• No known allergies to food and drugs
 OB GYNE HISTORY
• G2P2 (2002)
• G1 2003 Full Term LTCS for CPD PGH
• G2 2008 Full Term Repeat LTCS PGH

• Irregular menses, duration 5 days, consumes

4 packs/day
 FAMILY HISTORY
• (+) Hypertension – father
• (+) Bronchial Asthma – father
• (-) DM
• (-) Malignancy
• (+) PTB- sibling
 PERSONAL AND SOCIAL HISTORY
• High School Graduate
• Unemployed
• Housewife
• Non smoker
• Non Alcoholic Beverage Drinker
• No illicit drug use
PHYSICAL EXAM ON ADMISSION
Awake, coherent, speaks in sentences, in cardio-respiratory
distress
BP 90/70 HR 152 RR 36 Temp 37.4 °C
(+) pulsusparadoxus
(+) Jaundice
Pink conjunctivae, ictericsclerae
Supple neck, no cervical lymphadenopathy, JVP= 7cm H20
(+) Kussmaul’s sign
Equal chest expansion, (+) supraclavicular retractions,
decreased breath sounds at bases R>L, decreased vocal
fremitus, bilateral; (-) wheezes/ronchi/rales
Adynamicprecordium, tachycardic, regular rhythm, distinct
S1 and S2, no S3/S4, no P2 accentuation, AB at 5th ICS
LMCL, no murmurs appreciated
 PHYSICAL EXAM ON ADMISSION
Globular abdomen, normoactive bowel sounds,
(+) fluid wave, liver edge not palpable, soft,
non-tender, (+) bulging flanks
No cyanosis, (+) Grade III bipedal edema, pulses
full and equal
 DIAGNOSTICS/THERAPEUTICS
• CBC w/PC; PT/PTT
Hemoglobin 125
BUN (2.6-6.4) 5.94
Hematocrit 0.378
White Blood 16 Crea (53-115) 78
Cell Count Na (136-145) 136
Neutrophils 0.924 K (3.5-5.10) 3.4
Lymphocytes
Platelets
0.044
313
Blood Chemistry
Ca (2.12-2.52)
2.2
Albumin(34-50) 11
PT 13.9
activity 0.68 Mg (0.70-1.0) 0.73
INR 1.34 ALT (30-65) 88
PTT control 36.4 AST (15-37) 60
PTT patient 37.3
 DIAGNOSTICS/THERAPEUTICS
Urinalysis
Color Bright yellow
Transparency hazy
Sp. Gravity 1.010
pH 5.5
RBC 7/hpf
WBC 2/hpf
Bacteria 2/hpf
Sugar negative
Albumin negative
Epithelial Cells 1/hpf
Casts 0
 I
II Sinus Tachycardia, Normal
Axis, Low Voltage QRS
Complexes All Leads, Non-
specific ST – T Wave
III changes
V1 V4
VR
V2 V5
VL
AVF V3 V6

Atrial 150 Ventricular 150 PR 0.16 QRS 0.06 QTc 0.44

Qta 0.28 Axis deviation 18 EF 23.34
Enlarged Cardiac
Shadow
Poor Inspiratory
Effort

15 cm
23 cm
 Whole Abdomen Ultrasound
• Moderate Ascites
• Hepatomegaly
• Cholelithiasis
• Reactive gallbladder wall thickening
• Focal urinary bladder wall thickening
• Normal ultrasound of spleen, pancreas.
Abdominal aorta, para-aortic areas and
kidneys
 5/19 5/20 5/26 5/27 5/28 6/2
BUN (2.6-6.4) 5.94 7.24
Crea (53-115) 78 67 80
Na (136-145) 125 121 129
K (3.5-5.10) 3.4 4 4.2 4.9 3.2
Total Bilirubin 167.15
Direct Bilirubin 152.55
Indirect bilirubin 14.6
 Urinalysis
5/20 5/30 6/2
Color Bright yellow yellow yellow
Transparency hazy cloudy Sl. turbid
Sp. Gravity 1.010 1.010 1.010
pH 5.5 6.0 6.0
RBC 7/hpf 115/hpf 189/hpf
WBC 2/hpf 2/hpf 316/hpf
Bacteria 2/hpf 36/hpf 19/hpf
Sugar negative negative negative
Albumin negative +2 +2
Epithelial Cells 1/hpf
Casts 0 0 0
 9 Hospital Day
th

• 2D Echo with Doppler Studies were done

Normal-sized left ventricle with good wall motion and
contractility and preserved overall systolic function
Thickened pericardium with constrictive physiology
Mild mitral regurgitation
Moderate tricuspid regurgitation
Tricuspid and pulmonic sclerosis
Pulmonic regurgitation
Mild pulmonary hypertension by PAT
Note of pleural effusion
 Other Laboratories

• Sputum AFB: D1 – negative; D2 – negative

D3 – negative
• Sputum CS: light growth Klebsiella ozoanae
• Blood Culture (5/20 and 5/24) : negative
 Differential Diagnosis
•
 Primary Impression
• Constrictive Pericarditis probably fibrotic type
secondary to tuberculosis
• Community Acquired Pneumonia
• Chronic Passive Congestion of the Liver
 Pathophysiology (in Flowchart Form)

• Pulmonary TB  Extrapulmonary TB (Possible

areas of spread: Pleura, Pericardium, Kidney)
Pleural TB
 Pericardial TB  Acute Pericarditis  Chronic
Pericarditis  Chronic Constrictive Pericarditis
 Genitourinary TB: Kidney
 CHRONIC CONSTRICTIVE PERICARDITIS

• Inflammation and Repair  Granulation tissue

formation  Thickened fibrotic pericardium 
Forms a non-compliant shell around the heart [PE:
PMI at 5th ICS LPSB; Labs/Dx: Heart not enlarged as
seen in CXR; Echo showed thickened pericardium
with constrictive physiology and normal sized left
ventricle]  Inc force of contraction against a
constrictive encasing [Labs/Dx: ECG revealed low
voltage QRS consistent with constrictive physiology]
 Management and Treatment
(Tuberculous Constrictive Pericarditis)
• Treatment of underlying cause (TB)
– 6 months Antituberculous chemotherapy and
glucocorticoids
• Correction of Constrictive Pericarditis
– Pericardiectomy (Tx of choice for symptomatic
patients)
– Pericardiocentesis with extended intermittent
drainage (if with pericardial effusion)
 Management and Treatment
(Community Acquired Pneumonia)
 References
• Kumar V, Abbas AK, Fausto N and Aster JC. 2010.
Robbins and Cotran Pathologic Basis of Disease, 8th
Edition. Philadelphia: Sauders Elsevier.
• Bickley LS and Szilagyi PG. 2007. Bates’ Guide to
Physical Examination and History Taking, 10th edition.
Philadelphia: Lippincott Williams & Wilkins.
• Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo
DL, Jameson JL, Loscalzo J. 2008. Harrison’s Principles
of Internal Medicine, 17th Edition. The Mc-Graw Hill
Companies, Inc.