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Interactive Case Presentation
Doug Kutz MD
Past Medical History
58 yo male
Adult onset DM – on Insulin for 18 yrs. Last HBA1C 10.2%, Mild
proteinuria and CRI (30/1.7), Macrovascular disease
HTN w/ dias dysfunction
COPD – FEV1=1.0 liter/FVC=2.1 liter (little response to B-agonists)
ASCVD – Heart Cath ‘03: Occluded RCA, L with 40% distal Dz, EF 45%
Paroxysmal AFIB – Clopridogel instead of coumadin due to pt. pref
Multiple CVA’s (L cerebellar, R pontine, L caudate)
Prostate CA – s/p prostatectomy age 49
Dyslipidemia
80+ pack year Tobacco Abuse (Ongoing)
Depression/PTSD – intolerant of anything but MAOI Rx and Clonazepam
“Mononucleolis” with hepatitis while serving in Vietnam
Medications
Albuterol 2.5mg unit dose via nebulizer QID
Clopidogrel 75mg QD
Clonazepam 1mg TID
Furosemide 120mg po BID
NPH and Lispro Insulin
Metoprolol 25mg po bid
Pantorazole 40mg QD
Spironolactone 25mg QD
KCL 40meq po BID
Prednisone 10mg po QD
Phenelzine 30mg po BID
Family History
Mother died age 45 of Uterine CA
Father died age 76 sudden death
Brother died 67 lung CA and COPD
3 Healthy children ages 24 - 36
Admission 12/04
CC: Lightheaded and weak
HPI: Progressive nausea, some emesis, weakness, and
chills. Not using his insulin or taking his meds for 5 days
Exam:
Vitals Afeb, 148/82 supine, 108 irreg, 22, P.O. 96% (ra)
HEENT anicteric slcera, dry mm, neck “thick” no obvious jvd
Lungs diffusely diminished breath sounds
CV distant, irreg irreg, no murmur, no rubs
Abdm soft, nontender, nabs
Ext trace edema both ankles
Skin no jaundice or rashes
CNS nonfocal but slightly confused
Labs 12/04
WBC 15.2k, H/H 9.0/26.9, Plt 293k
Bun/cr 2.9/63 Nml lytes
Glucose 390, Slight pos serum ketones
Ast 6098, Alt 1601, Alb 2.8, Alk 386, Bili
0.9, Nh3 51
Coags nml
Troponin I 1.94
ECG: AFIB w/RVR, LVH, nonspecific ST
Imaging/Other Studies 12/04
CT chest: COPD and pericardial effusion
U/S Abdm: nml liver and GB, no masses
Echocardiogram: Large pericardial effusion
without tamponade, LVH with diastolic
relaxation abnormality
RN: “He is becoming
hypotensive”
Drug Interactions: Phenelzine
5-HT agonists
Buproprion, SSRI,
mirtazapine
Alpha 2 agonists
Decongestants
Dextromethorphan
Ginseng
Hydralazine
Most sedatives
Linezolid (14 days)
Licorice
Metoclopramide
Promethazine
SAMe
Sulfonylurea
Sympathomimetics
Trazodone
Hospital Course
Aggressively rehydrated
Oliguria and Azotemia resolved after 3 days
Liver function normalized over 3-4 days
Hepatitis serology negative
AFIB did not recur, not a candidate for
anticoagulation
Discharge Diagnoses
Severe dehydration due to severe
hyperglycemia/medication noncompliance
and possible viral GE
Acute Tubular Necrosis
Ischemic Hepatitis
Cardiac “Enzyme Leak”
Pericardial Effusion, Incidental/? viral
Paroxysmal AFIB
Heart disease and Hepatic dysfunction
Hepatic congestion
Typically due to exacerbation of chronic CHF
Liver enlarged and firm on exam
Modest elevations in ALT, AST, LDH, GGT
and sometimes alk phos, total bili, and slight
decrease in albumin
Mild transient jaundice can occur
Chronic congestion can lead to “cardiac
cirrhosis” with fibrosis of liver on biopsy
Cardiogenic Ischemic Hepatitis
More acute and severe fall in cardiac output
(such as with an acute MI or Severe CHF)
Enzyme levels often >10x normal
Coagulopathy and Functional renal
impairment can be associated
No specific marker for Dx, but typically the
transaminases drop >50% in first 72hrs of
onset
Outpatient Visit 3/05
Dyspnea and pallor, cough.“Considering Hospice”
Exam:
Vitals 110/76, 68 reg, Afeb, 22, Wt. up 4# in 1month,
pulse ox 93% on room air
HEENT dry mm, JVP not visible
Lungs: Diminished diffusely, BS absent in right
lower ½ w/ dullness
CV: RRR distant, no murmur
ABDM: NABS, NT, Soft
Ext: slight increase edema (now 1+)
Outpatient Labs 3/05
WBC 9.3k, H/H 10/34.3, Plt 220
BS 248, Bun/Cr 27/1.3, Nml lytes
Lfts nml except alk 346
TSH 1.70
BNP 467 (nml)
EKG unchanged
Outpatient Thoracentesis 3/05
Red Hazy fluid with many RBC’s
500 nuc cells (4% seg, 22% lymphs, 74% mono’s)
Glucose 238
LDH 82
Protein 1.4 (serum 7.7)
GS + Cx neg
Cytology neg
Outpatient Imaging 3/05
Echocardiogram LVH with no wall motion
abnormalities, nearly resolved pericardial
effusion.
Admission 4/4/05
CC:Worsening edema, dyspnea and falls
HPI:
Despite increasing doses of furosemide, fluid build-up
in legs has extended up to chest wall, now distended
and bloated abdomen, weight is up 30#. Positive orthop
and PND.
Dyspnea continues and is now associated with a cough.
Cough is associated with dizziness and lightheadedness.
Cough produces yellow sputum 1-2 tbsp per day.
Fell yesterday after a coughing spell and hit his R orbit;
now has a “black eye”.
Physical Exam 4/05
Vitals: 156/97, 94, 22, 97.8 Wt up 24# from 12/04
Pulse Ox: 90% RA, 94% on 2L NC
HEENT: New circular ecchymosis R orbit, R scleral
hemorrage, JVP not visible due to habitus and edema
Lungs: Absent R base to ½ way up, w/ dullness to
percussion, BS otherwise diminished diffusely, no wheeze
CV: Irr Irr w/no murmur, distant, no gallups or rubs
Abdm: Distended with no localized tenderness, NABS,
prominent liver, no splenomegaly, ? Shifting dullness,
pitting up to costal margins
Ext: 3+ pitting edema bilaterally, pos sacral edema
Initial Laboratory Data 4/05
Heme: Wbc 11.2, H/H 10.3/32.3, Plt 295
Renal/Lytes: Bun/Cr 36/1.3, Gluc 131, Ca
9.2, Na 141, K 4.8, Mg 2.3
Hepatic:Alt/Ast 40/52, AlkP 368, Alb 3.9,
Ammonia 26
Coags: nml
Cardiac: Enz neg, BNP 2800
Other: D-dimer 3000, U/A 2+ prot
Imaging 4/05
CXR: R effusion, mild PVC
CT chest: No PE, R pleural eff, some
obstructive changes
Head CT: no change
U/S abdm: normal except ascites
Echo: Nml wall motion, LVH w/ dias
dysfunction, trace effusion
Fluid Studies 4/05
Pleural Fluid: almost identical to outpatient
Ascitic Fluid:
Yellow, clear, moderate rbc’s
500 nuc cells (20% segs, 15% lymphs, 61% mono’s)
Glucose 177
Amylase 20
Alb 1.9 (serum 3.9) (s:a gradient 2.05)
GS and Cx neg
Diuresed 30#
JVP now visible to
10cm
“A Diagnostic Study was
Obtained”
“Doctor I have to get out of
here !”
Heart Cath 4/05
Arterial press 139/86
LV end-dias pressure 29mmHg (3-12)
Pulm arterial pressure 51/25 (15-30/4-12)
Wedge pressure 34 (2-10)
Kussmaul’s sign noted on right atrial
pressure trace, mean pressure RA 26 (2-8)
Equalization of LV and RV dias press, as
well as LV and RA dias pressures
Tissue Diagnosis:
Fibrotic Pericardium, up to 5mm thick.
Pericarditis
Can present in 4 ways:
Acute pericarditis
Incidental effusion
Tamponade
Constriction
Acute Pericarditis
85-90% idiopathic, 1-4% viral
Remainder of cases are post MI, other infx, AAA,
trauma, neoplastic, post surgical or XRT, uremic,
connective tissue disease or drug induced
Classic ECG changes: diffuse ST elevation
Pericardial rub pathognomonic (85% develop)
Pericardiocentesis indicated for tamponade, or if
strong suspicion of bacterial infx or neoplasm
Serologic studies not very helpful (<10% dx)
“Troponin Leak” occurs in 35-50%
Tamponade
Occurs in 15% idiopathic, but up to 60%
with Tb, bacterial or neoplastic etiology
Presents with “Beck’s triad”
• Hypotension
• Quiet heart sounds
• Increased Jugular venous pressure
Can also note compensatory tachycardia and
pulsus paradoxus (fall in SBP >10 during insp)
Constrictive Pericarditis
Chronic fibrous and/or calcific thickening
of the pericardium that leads to abnormaly
elevated diastolic filling pressures
Most commonly idiopathic after acute or
sub acute pericarditis (Tb still most
common in undeveloped countries)
Post cardiac surgery and radiation therapy
becoming more common
Constrictive Pericarditis…..
Clinical findings:
Pulsatile hepatomegaly
Pericardial knock (early diastole)
Kussmaul’s Sign: JVP rises (or at least fails to
fall) during inspiration, due to separation of the
cardiac pressures from the thoracic pressure
changes in respiration
Constrictive Pericarditis…..
Differential Diagnosis
Other causes of right heart failure
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•
•
•
Restrictive Cardiomyopathy
PE or Pulm HTN
Right ventricular infarction
Mitral stenosis or Tricuspid Disease
Cirrhosis or Hepatic Vein Thrombosis
Acute Renal Failure or Nephrotic syndrome
SVC obstruction or Lymph obstruction
Myxedema
Drug Induced (Ca channel, minoxidil, steroids,
“glitazones”, NSAIDs,)
Constrictive Pericarditis…..
Diagnosis
Unfortunately clinical findings not very specific
Key echo findings are that of a thickened pericardium,
a septal “bounce”, inspiratory decrease in pulmonary
venous flow, and normal relaxation indices.
MRI is 88% sens, 100% specific using same criteria
above
Cath findings that are most specific are equalization of
RV and LV end dias pressures.
No widely accepted “gold standard”
Constrictive Pericarditis….
Treatment: Pericardectomy
Use caution with diureses pre-op
1 month follow up