Interactive Case Presentation

1. Interactive Case Presentation Doug Kutz MD

4. Medications

7. 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

8. 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

10. 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

11. RN: �He is becoming hypotensive�

12. 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

13. 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

14. 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

15. 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

17. 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 � w/ dullness CV: RRR distant, no murmur ABDM: NABS, NT, Soft Ext: slight increase edema (now 1+)

18. 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

20. 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

21. Outpatient Imaging 3/05 Echocardiogram LVH with no wall motion abnormalities, nearly resolved pericardial effusion.

22. 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�.

23. 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 � 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

24. 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

26. 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

27. 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

29. �A Diagnostic Study was Obtained� �Doctor I have to get out of here !�

33. 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

34. Tissue Diagnosis: Fibrotic Pericardium, up to 5mm thick.

35. Pericarditis Can present in 4 ways: Acute pericarditis Incidental effusion Tamponade Constriction

36. 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%

37. 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)

38. 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

39. 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

40. Constrictive Pericarditis�.. Differential Diagnosis Other causes of right heart failure 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,)

41. 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�

42. Constrictive Pericarditis�. Treatment: Pericardectomy Use caution with diureses pre-op

43. 1 month follow up