CPC PRESENTATION

GENERAL DATA:

• Age : 21 years
• Gender : Male
• Civil status : single
• Residence : Malabon city
• Occupation : Fast food worker
CHIEF COMPLAINT: Persistent Cough
HISTORY OF PRESENT ILLNESS:

✓ On and off cough for three months.

✓ Low grade fever.
✓ Lymphadenopathies.
✓ OTC medicines were given for temporary cough relief.
✓ Weight loss
✓ Episodes of difficulty in breathing.
SALIENT FEATURES
• Cough
• Fever
• Lymphadenopathies
• Weight loss
• Difficulty of breathing
PAST MEDICAL HISTORY:
Patient is non-diabetic, non-asthmatic, and uneventful
FAMILY HISTORY : unremaremarkable
PHYSICAL EXAMINATION:
• Vital signs
 • BP:140/90
• HR:105
• RR:24
• General:
• Fever
• Weight loss
• Fatigue
• Head and neck:
• Pink palpebral conjunctivae
• Anicteric sclerae
• Lymphadenopathy:present in cervical region
• Cardiovascular:
• Pulse:weak
• Heart sounds : not appreciated with distinct S1 and S2 ,suggestive of a dynamic
precordium due to pericardial effusion
• Gastrointestinal
• Abdomen: Flat with normoactive bowel sounds
• Liver : Edge palpable, but significance unclear without further information
• Skin: Moist and warm
• Nervous System: pateint was conscious but The GCS score getting change each day after
patient transfers to MICU
CLINICAL CONSIDERATION / INITIAL DIAGNOSIS:
Community acquired pneumonia
DIFFERENTIAL DIAGNOSIS:

1. Tuberculosis ( Tuberculous pericarditis)

Rule in
Chronic cough
Fever
Cervical Lymphadenopathy
 Pleural effusion
Tamponade
Hypocalcemia
Periicardial effusion
Cardiomegaly
Wbc increases
Neutrophil increases

Rule out
No definite hx of tb
Night sweats
Hemoptysis
Need further testing to rule out
Hypernatremia( in doubt because two values have been given )

2. Lymphoma

Rule in

SOB
Fever
Fatigue
Wt loss
Increased wbcs
Rule out
Flat abdomen

3. Hypoparathyroidism:
Rule in
Low grade fever
Weight loss
Severe hypocalecimia
Anemia
Rule out
Cough
Lymphadenopathy
Magnesium level needed

4. Lung malingnancy:
Rule in
 Cough
Dyspnea
Wheezing
Weight loss
Anemia
Rule out
Hemoptysis
Chest pain
Further test need to be done

5. COMMUNITY ACQUIRED PNEUMONIA

Rule in
Cough
Lymphadenopathy
Fever
Consolidation in lungs
Pleural effusion
Weight loss
Weakness
High WBC count
Sob

Rule outs
Sputum culture needed
Night sweats

FINAL DIAGNOSIS:
Tuberculosis ( Tuberculous pericarditis)

1. Cough+
2. low fever+
3. tiredness+
4. dypnea+
5. Active TB outside EXTRAPULMONARY TB ( 15% of all TB cases)- possible sites for active TB
outside lungs are kidney liver, fluid sureounding the brain and spinal cord), heart muscle,
lymph nodes
6. chest pain +
7. weight loss+
8. Tb presenting with pericardial disease complicated by cardiac tamponade is rare. It
occurs in the context of immunosuppression- reduction in the capacity of immunity due to
TB
9. TB pericarditis is also rarely seen form of extra pulmonary TB- common cause of massive
pericardial effusion
10. cardiomegaly
11. TB ass pneumonia- same as sym of TB, WBC increases, neutrophils increases. Lesions are
more common in the upper and mid lobs ( our px has mid and lower lobe involve)
12. CAP possibly found during admission
13. HYPOCALCEMIA is seen in TB - ca and vit D has an important role in the control of
tuberculous infxn. The ability to kill MT by macrophages and monocytes is reduced due to
absence of extra cellular and intracellular ca. similarly vit D deficiency is ass with an increase
risk for tuberculosis infnx. In RX of TB usually ca and vit D supplement is given for anti-
tuberculous therapy to be responsive
14. VIT D HAS A DIRECT ROLE IN KILLING MYCOBACTERIUM TUBERCULOSIS
15. edema after thoracentesis manifesting is one the complications after tha procedure
( still in doubt ?)
16. Possible color of plural fluid after thoracentesis- darker in colour but better in clarity -
parapneumonic effusion. Dark in colour and high in protein possibly bloody effusion
resulting from a malignancy LDH high in the pleural fluid

PATHOPHYSIOLOGY
LAB FINDINGS
CBC values :
Rbc-3.9, hgb-86, hct-0.26, suggests anemia .
wbc-15.9, elevated WBC suggests inflammation or infection.
neutro-88, elevated value suggests Inflammation
reactive lymphocyte-1, may indicate immune response
For electrolytes: Sodium-127, hyponatremia ( in doubt )
Ca- 1.85 severe hypocalcemia
% activity (PT) and INR (PT) suggest that the clotting activity is lower than normal control
A CK-MB level of 63ng/ml indicates elevated levels
A troponin level of 6.61ng/ml indicates an elevated levels.
 Laboratory correlation

The ECG report suggests that massive pericardial effusion with cardiac tamponade is likely due
to an infectious or inflammatory process, possibly pericarditis. Additional imaging, such as CT or
MRI, is recommended for further insights.

The X-ray findings indicate parenchymal consolidation in the right, mid, and lower lung,
consistent with pneumonia. Symptoms like persistent cough, low-grade fever, and difficulty
breathing align with this diagnosis. Further CT scan or MRI can provide detailed information for
targeted treatment.

CBC results reveal elevated RBC and WBC counts, particularly neutrophils, suggesting an
inflammatory or infectious process. Decreased hemoglobin and hematocrit levels indicate
anemia associated with chronic inflammation. Lymphocyte reduction may signify their
migration to the site of infection.

The prolonged PT of 17.3 seconds is attributed to the severe illness and multi-organ
involvement, possibly causing changes in the clotting cascade. Factors like DIC or consumptive
coagulopathy may contribute to this prolonged PT.

In clinical chemistry, hyperkalemia is observed, likely stemming from cell damage during
inflammation or infection, along with potassium release from cells in conditions like tissue
breakdown.

Overall, the patient’s clinical picture suggests a complex interplay of infectious, inflammatory,
and multi-organ involvement, emphasizing the need for comprehensive diagnostic and
treatment approaches.

TREATMENT AND MANGEMENT:

● At the day of admission after x-ray THORACENTESIS was done. It is the procedure to
remove fluid or air from around lungs. Its done to test the fluid for infection or other
comorbidities and to relieve chest pressure that makes the patient tough to breath.
● Ceftriaxone and azithromycin is given – antibiotic which has good penetration of the
pleural space 44-50
● After admission antibiotic was contiued and the patient still maintained the oxygen
saturation at 1 LNC
● Tramadol 50mg IV was given for the pain

● Blood transfusion with 2 packs of RBC given as the patient is anemic ( blood transfusion
is if an illness prevents your body from making blood)
● Intubed as the pateint is having dyspnea

● Dexamethasone is given ( it decreases the production of inflammatory cytokines,

alleviated alveolar epithelial and endothelial cell damage, and reduced pulmonary
edema.
● Pericardiocentesis is done – its done to remove the fluid that hs been build up in the sac
around the pericardium
● Diphenydramine is given

● All the medication stopped untill intubation

● At day 4 intubated citicholine 2 gms is given- as the px is not opening the eye its
expected to have some neurological effects
● Ca gluconate at 10% dose is given – as the 2nd 2D echo revelaed msame result of massive
pericardial effusion with signs of cardiac tamponade
● Antibiotics of azithromycin and levoflaxcin is continued

● As the babinski sign was positive, started with dopamine 5 mg (it the indication of
dysfunction of CST) – dopamine is given to stimulate as it the precursor to NE in NA
nerve and also a neurotransmitter
● Omeprazole q12 and iselpin q8 was given for GI bleeding

● As the bp comes down to (93/45 NE is given)

● Px bp palpatory CR 120 after 30 mins BP 0 and CR 0

 ● CPR EN 1mg q3mins given( it increases arterial blood pressure and coronary perfusion
during CPR) and NaHCo3 50mg Iv
● The patient expired

CAUSE OF DEATH:
1. Immediate cause- Cardiogenic Shock (due to cardiac failure because of an increase in
intrapericardial fluid pressure that exceeds atrial venous pressure, thereby impending venous
return to the heart causing hypotension and sudden cardiac arrest)
2. Antecedent cause - massive pericardial and plural effusion with cardiac tamponade, cardiac
compromise ( fluid filled pericardium compress heart where chambers reduces in size causing
abrupt increase in pericardial pressure ,holodiastolic compression leads to complete absence of
filling during diastolic ) and HIE
3. Underlying cause- TUBERCULOSIS infection