INTERNAL

MEDICINE
Case Presentation

University of Cebu School of Medicine

Block 1
Angob | Balbutin | Lo | Omol | Queniahan | Sanchez
 Informant: Patient
%Reliability: 90%

• 22 years old
• Female
• Married
• Housewife

CHEST PAIN
 Past Medical History

X Non-Hypertensive  Appendectomy (2008)

X Non-Diabetic  G3P1(1021)
X Non-Asthmatic  LMP: July 1, 2018
 Family History

 Hypertension
 Diabetes X Asthma
 Cancer X Thyroid Problems
 Cardiac Problem
Personal and Social History

 Smoker: 1.2 pack years

 Alcoholic beverage drinker
 Illicit drug use
(Methamphetamine)

X Stopped smoking and

drinking 3 months ago
History of Present Illness
4 weeks Prior to Admission

Left flank pain X No dysuria

X No hematuria
Fever (Tmax 39 C) X No urinary frequency
Chills and urgency
History of Present Illness
4 weeks Prior to Admission
Mendero Medical Center
• Managed as a case of UTI
• Edematous
• Piercing chest pain, PS 9/10,
radiating to the back,
specifically at left area
• Unrecalled medications
• Condition did not improve
History of Present Illness
3 weeks Prior to Admission
Vicente Sotto Memorial Medical Center
• 2D Echo: mild pericardial effusion
• Medications given
 Colchicine 500 mg, 1 tab TID
 Ivabradine 5 mg, 1 tab BID
 Omeprazole 40 mg, 1 tab OD
 Aspirin 80 mg
 Multivitamins 1 cap OD
History of Present Illness
3 weeks Prior to Admission
Vicente Sotto Memorial Medical Center

• Discharged after 10 days

• Condition improved
History of Present Illness
1 week Prior to Admission
• Intermittent piercing chest pain, PS 5-9/10,
radiating to back specifically at left area
• Associated symptoms
 exertional dyspnea
 2-3 pillow orthopnea
• Continued taking medications
• No consult done
• Condition tolerated
History of Present Illness
Two Days Prior to Admission

• 2D Echo
 Massive pericardial effusion with early
signs of tamponade
 Concentric left ventricular remodeling
with adequate contractility and normal
systolic and diastolic functions
 Mild mitral regurgitation
 Mild tricuspid regurgitation
History of Present Illness
Two Days Prior to Admission

• Advised for admission

• For pericardial window and
pericardiostomy tube insertion
History of Present Illness
On the day of admission

• Intermittent piercing chest pain, PS 5-9/10,

radiating to back specifically at left area
• Associated symptoms
 exertional dyspnea
 2-3 pillow orthopnea
• Relieved by sitting up and leaning forward
 Review of Systems
• General: fever, chills, sweats, weight loss
• Skin: rash, bruising
• Eyes: pain, diplopia
• ENT: nasal discharge, sore throat
• Neck: tenderness, neck swelling
• Cardiovascular: chest pain
• Respiratory: exertional dyspnea and orthopnea
• GI: nausea, vomiting, diarrhea, pain
• OB/GYN: vaginal discharge, bleeding, cramping pain
• Musculoskeletal: joint pains
• Neurological: weakness, headache, seizure, dizziness
 Physical Examination
Examined an awake, afebrile , coherent patient, in pain, not in respiratory distress

BP: 120/80mmHg RR: 24cpm

PR: 76bpm Temp: 36
O2 Sat: 99% with O2 support at 2L/min

Skin: dry, warm, good mobility and turgor

Eyes: anicteric sclerae, pink palpebral conjunctivae
Mouth: moist lips and pink buccal mucosa
Neck: neck veins engorged, no cervical lymphadenopathies
 Physical Examination
Chest and lungs: equal chest expansion, decreased breath
sounds on bibasal area
Cardiovascular: JVP is 10.3cm, normal rate, regular rhythm,
muffled heart sounds at apex, (+) pericardial friction rub,
(+) pulsus paradoxus
Gastrointestinal: flabby, normoactive bowel sounds,
generally tympanitic, soft, nontender
Genitourinary: (-) KPS
Extremities: strong peripheral pulses bilaterally, CRT <2s, no
bipedal edema
All other PE findings were unremarkable
 Salient Features
• 22-year old female • Engorged neck veins
• Chest pain radiating to • JVP=10.3 cm
the back • Muffled heart sounds at
• Relieved by sitting up the apex
and leaning forward • (+) pericardial friction
• Exertional dyspnea rub
• 2-3 pillow orthopnea
Working Impression

T/C Tuberculous Pericarditis with

Pericardial Effusion and Cardiac
Tamponade
T/C Tuberculous Pericarditis with
Pericardial Effusion and Cardiac
Tamponade
HISTORY

 Chest pain radiating to the

back
 Relieved by sitting up and
leaning forward
 Dyspnea
 2-3 pillow orthopnea
T/C Tuberculous Pericarditis with
Pericardial Effusion and Cardiac
Tamponade

PHYSICAL EXAMINATION
 Jugular vein distention
 JVP=10.3 cm
 Muffled heart sounds
 Pericardial friction rub
 Pulsus paradoxus (20 mmHg difference)
T/C Tuberculous Pericarditis with
Pericardial Effusion and Cardiac
Tamponade

Risk Factors
 Exposure to person with PTB
 PTB is endemic in the Philippines
Differential Diagnoses
 Acute Coronary Syndrome
 Chest pain, occurring even
at rest
 Exertional Dyspnea
X Chest pain
exacerbated upon
inspiration
X Chest pain radiating
to the back only
X Chest pain relieved
by sitting up and
leaning forward
AORTIC DISSECTION
 Chest pain radiating X Chest pain is not described
to the back as tearing or stabbing
 Exertional Dyspnea X Chest pain not of sudden
 Body malaise onset
X No history of connective
tissue disease
X Not
hypertensive/hypotensive
 Pulmonary Embolism
 Chest pain, occurring even
at rest
 Exertional Dyspnea
 One-year use of
Methamphetamine
X No sudden-onset
dyspnea
X No history of prolonged
immobilization
X Well’s Score = 0
Diagnostics
 Diagnostics

Definitive:
• 2D echo – for localization and identification of
the quantity of pericardial fluid
 Diagnostics

Supportive:

• ECG
• Chest Xray
• CBC- to determine hemodynamic status of the patient

 07-19-18 RESULTS
Hemoglobin 10
Hematocrit 33.4
WBC 4.64
Segmenters 55
Lymphocytes 32
Monocytes 10
Eosinophils 2
Basophils 1
Bands -
MCV 82.7
MHC 26.92
Platelets 191
• Coagulation Studies

TEST NAME RESULT UNITS REFERENCE RANGE

CONTROL 13.1 Sec -

PRO-TIME 13.1 Sec 11.5-15.5

% ACTIVITY 100 70-100

INR 1 <1.2
07-19-18 RESULT REFERENCE RANGE
(min sec)

Clotting time 7’0” 7.0-15

Bleeding time 5’30” 2.0-8.0

• Pericardial fluid analysis – to check for presence of
microorganism and to identify the etiology of effusion
• LDH
• Protein
• AFB smear
• Pericardial fluid C/S
• Cell Cytology
Therapeutics
 Therapeutics

Definitive:
• Creation of pericardial window and
pericardiostomy tube
 Therapeutics
Supportive:

Medications
• Aspirin 80 mg/tab OD
• Colchicine 500 mcg/tab TID
• Omeprazole 40 mg/tab before breakfast
• Ivabradine 5mg/tab TID
• Multivitamins 1 cap OD
 Therapeutics

Other non-pharmacologic interventions:

• Physical activity restriction
• Monitor V/S every hour
• O2 inhalation at 2LPM
• Full diet
 Course in the Ward
Hospital Day 1 (July 20, 2018)
S (+) chest pain radiating to the left shoulder (+) body malaise
(+) non productive cough (+) dyspnea
(-) fever

O BP: 110/80mmHg HR: 82bpm RR: 19cpm

Temp: 36.1C O2 sat: 97%
Eyes: anicteric sclerae, pink palpebral conjunctivae
C/L: equal chest expansion, clear breath sounds
CVS: muffled heart sounds, (+) friction rub
Abdomen: NABS, soft, nontender
Extremities: strong pulses (2+), CRT <2 seconds, (-) edema
I: 1210ml O: 900ml (+) 310
 Course in the Ward
Hospital Day 1 (July 20, 2018)
 A Massive pericardial effusion with signs of cardiac tamponade
probably secondary to tuberculous pericarditis
s/p Appendectomy (2008)

 P  For Pericardial Window

Medications Given:
1. Cefoxitin 1 gram IVTT single dose at 9:00 AM
2. Ivabradine (COROLAN) 5mg tablet 1tab BID
3. Colchicine 0.5mg tablet 1 tab TID
4. Omeprazole 40mg before breakfast
 Course in the Ward
Post-Op Day 1, Hospital Day 2 (July 21, 2018)

S (+)pain at post-op site ps:7/10 (+) body malaise

(-) dyspnea (-) fever

O BP: 100/80mmHg HR: 82bpm RR: 20cpm

Temp: 36.2C O2 sat: 97%
Eyes: anicteric sclerae, pink palpebral conjunctivae
C/L: equal chest expansion, clear breath sounds
CVS: distinct heart sounds, no murmurs
Abdomen: NABS, soft, nontender
Extremities: strong pulses (2+), CRT <2 seconds, (-) edema
I: 2940ml O: 1230ml (+) 1510
 Course in the Ward
Post-Op Day 1, Hospital Day 2(July 21, 2018)
Cell Count and Differential Count of Culture of 0-1 pus cells/OIF
Pericardial Fluid Pericardial (Gram)
Fluid No
Macrosco Color Dark Yellow microorganisms
pic Appearance Cloudy seen 
Volume 20ml AFB Staining of No AFB/300 Visual
Microscop RBC 3000/cumm Pericardial Fields
ic WBC 800/cumm Fluid
Differentia Neutrophil 83 LDH 186
l Count Lymphocyte 17 Total Protein 60.56
s
HBV-DNA Non-reactive
Monocytes 0
HCV-RNA Non-reactive
Eosinophil 0
Retroviral-RNA Non-reactive
Basophil 0
 Course in the Ward
Post-Op Day 1, Hospital Day 2 (July 21, 2018)

Chest X-ray

July 19
July 21
 Course in the Ward
Post-Op Day 1, Hospital Day 2(July 21, 2018)
Acute Pericarditis
 A Massive pericardial effusion with signs of cardiac tamponade resolved
s/p Pleuropericardial window (7/20/18)

For 2DED with left Doppler - 7/23

 P Refer for acute onset of desaturation, hypotension and chest pain
Monitor drain in absolute figures
Change dressing
Medications:
1. Tramadol+Paracetamol 1 tab BID
2. Cefoxitin 1g IVTT Q8h
3. Ivabradine (COROLAN) 5mg tablet 1tab BID
4. Colchine 0.5mg tablet 1 tab TID
5. Aspirin (ASPILETS) 80mg tablet OD
6. Omeprazole 40mg before breakfast
 Course in the Ward
Post-Op Day 2, Hospital Day 3 (July 22, 2018)
S (+)pain at post-operative site 4/10 (-) body malaise
(-) cough (-)dyspnea (-) fever

O BP: 100/80mmHg HR: 88bpm RR: 19cpm

Temp: 36.8C O2 sat: 99%
Eyes: anicteric sclerae, pink palpebral conjunctivae
C/L: equal chest expansion, clear breath sounds
CVS: adynamic precodium, normal rate and regular rhythm, no murmur
Abdomen: NABS, soft, nontender
Extremities: strong pulses (2+), CRT <2 seconds, (-) edema
I: 1800ml O: 1450ml (+) 430
Chest tube Drainage: 256 cc in 24 hours
 Course in the Ward
Post-Op Day 2, Hospital Day 3(July 22, 2018)
Chronic Pericarditis
  Massive pericardial effusion with signs of cardiac tamponade
A resolved
s/p Pleuropericardial window (7/20/18)
Medications:
 P 1.  Tramadol+Paracetamol 1 tab BID
2. Cefoxitin 1g IVTT Q8h
3. Ivabradine (COROLAN) 5mg tablet 1tab BID
4. Colchine 0.5mg tablet 1 tab TID
5. Aspirin (ASPILETS) 80mg tablet OD
6. Omeprazole 40mg before breakfast
 Course in the Ward
Post-Op Day 3, Hospital Day 4(July 23, 2018)

S (+)pain at post-operative site 3/10 (-) body malaise (-) cough

(-)dyspnea (-) fever

O BP: 100/70mmHg HR: 81bpm RR: 18cpm
Temp: 36.5C O2 sat: 98%
Eyes: anicteric sclerae, pink palpebral conjunctivae
C/L: equal chest expansion, clear breath sounds
CVS: adynamic precodium, normal rate and regular rhythm, no
murmur
Abdomen: NABS, soft, nontender
Extremities: strong pulses (2+), CRT <2 seconds, (-) edema
I: 1565ml O: 1690ml (-) 125ml
Chest tube Drainage: 265cc in 24 hours
 Course in the Ward
Post-Op Day 3, Hospital Day 4(July 23, 2018)

2D echo Result:
• Concentric left ventricular remodeling with adequate
contractility
• Normal right ventricular systolic function
• Tricuspid regurgitation mild
• Aortic regurgitation mild
• Mild Pulmonary Hypertension with mild pulmonary
regurgitation
• Moderate pericardial effusion without signs of
tamponade
 Course in the Ward
Post-Op Day 3, Hospital Day 4(July 23, 2018)

Acute Pericarditis
  Moderate pericardial effusion with resolved cardiac tamponade
A s/p Pleuropericardial window (7/20/18)

 P  Shift Cefoxitin IV to Cefixime 200mg/tab PO BID

Terminate IVF
Medications:
1.  Tramadol+Paracetamol 1 tab BID
2. Cefixime 200mg/tab BID
3. Ivabradine (COROLAN) 5mg tablet 1tab BID
4. Colchine 0.5mg tablet 1 tab TID
5. Aspirin (ASPILETS) 80mg tablet OD
6. Omeprazole 40mg before breakfast
 Course in the Ward
Post-Op Day 4, Hospital Day 5 (July 24, 2018)

S (-) cough
(+) pain at post-operative site 3/10 (-) body malaise
(-)dyspnea (-) fever
BP: 100/70mmHg HR: 81bpm RR: 18cpm
Temp: 36.5C O2 sat: 98%
O Eyes: anicteric sclerae, pink palpebral conjunctivae
C/L: equal chest expansion, clear breath sounds
CVS: adynamic precodium, normal rate and regular rhythm, no murmur
Abdomen: NABS, soft, nontender
Extremities: strong pulses (2+), CRT <2 seconds, (-) edema
I: 200ml O: 486ml (-) 230ml
Chest tube Drainage: 86cc
(10AM) pull out of pericardiostomy tube
 Course in the Ward
Post-Op Day 4, Hospital Day 5(July 24, 2018)
Date   7/19/18 7/24/18
CBC Hemoglobin 10 11.3
Hematocrit 33.4 34
WBC 4.64 3.61
Segmenters 55 60
Lymphocytes 32 31
Monocytes 10 6
Eosinophil 2 3
Basophil 1 0
Bands  - -
MVC 87.2 85
MCH 26.2 28.2
Platelets 191 188

Culture Body Fluids Preliminary Report

7/24 No growth after 4 days of incubation
 Course in the Ward
Post-Op Day 4, Hospital Day 5(July 24, 2018)
 Course in the Ward
Post-Op Day 4, Hospital Day 5(July 24, 2018)
 Course in the Ward
Post-Op Day 4, Hospital Day 5(July 24, 2018)

  Acute Pericarditis with Moderate Pericardial Effusion with resolved

Cardiac Tamponade
A
Medications:
 P 1.  Tramadol+Paracetamol 1 tab BID
2. Cefexime 200 mg BID
3. Ivabradine (COROLAN) 5mg tablet 1tab BID
4. Colchine 0.5mg tablet 1 tab TID
5. Aspirin (ASPILETS) 80mg tablet OD
6. Omeprazole 40mg before breakfast
 TAKE HOME
MEDICATIONS
Time
Medication Frequency/
Remarks
(to consume) Duration AM Noon PM

Cefexime (TERGECEF) 1 tab 2x a 8AM   6P For 10 days until

200mg tablet day M August 3, 2018
Tramadol + Paracetamol 1 tab 3 x day       As needed for pain
(ALGESIA)
Omeprazole (RISEK) 1 tab once a 6AM     For 7 days
40mg tablet day before
breakfast
Isoniazed + Rifampicin + 3 tabs once a 6AM     For 2 months until
Pyrazinamide + day before September 24, 2018
Ethambutol breakfast
(FIXCOM 4 )tablet
 TAKE HOME
MEDICATIONS
Time
Medication Frequency/
AM Noon PM Remarks
(Maintenance) Duration
Multivitamins (REGERON- 1 cap once a 8AM      
E)capsule day
Vitamin B complex tablet 1 tab once a day 8AM      

Ivabradine (COROLAN) 5mg 1 tab 2x a day 8AM   6PM  

tablet
Colchicine 0.5mg tablet 1 tab 3x a day 8AM 1PM 6PM After lunch

Aspirin (ASPILETS) 80mg 1 tab once a day   1PM    

tablet
CASE DISCUSSION
 Pericarditis: Epidemiology &
Etiology

• 0.1% hospital admissions for chest pain

• 5% ED visits for chest pain in the absence
of MI
• 0.20% of cardiovascular admissions
• Viral vs TB

2015 ESC Guidelines for the diagnosis and management or pericardial diseases
 Pericarditis: Epidemiology &
Etiology

• 78% idiopathic
• 5.1-7% neoplasia
• 1.7 – 7% autoimmune
• 1% bacterial

2015 ESC Guidelines for the diagnosis and management or pericardial diseases
 Pericardial effusion: Epidemiology & Etiology

• idiopathic up to 50%
• cancer (10–25%)
• infections (15–30%)
• Iatrogenic causes (15–20%)
• connective tissue diseases (5–15%)
• TB endemic countries (60%)
• Pericarditis + effusion = malignant or
infectious up to 50%

2015 ESC Guidelines for the diagnosis and management or pericardial diseases
 Cardiac tamponade: Epidemiology &
Etiology

2015 ESC Guidelines for the diagnosis and management or pericardial diseases
Harrison’s Principles of Internal Medicine, 19th edition
2015 ESC Guidelines for the diagnosis and management or pericardial diseases
2015 ESC Guidelines for the diagnosis and management or pericardial diseases
2015 ESC Guidelines for the diagnosis and management or pericardial diseases
2015 ESC Guidelines for the diagnosis and management or pericardial diseases
Pathophysiology
 Visceral
Pericardium

Pericardial Fluid
15 – 50 mL

Lymphatics

BRAUNWALD’S Heart Disease Textbook of Cardiovascular Medicine NINTH EDITION

 Infection /
Inflammation

Increased adrenergic
Effusion stimulation and
parasympathetic
Reduction of cardiac withdrawal
chamber volume

Decreased Cardiac
Maintain Cardiac Output
Output

BRAUNWALD’S Heart Disease Textbook of Cardiovascular Medicine NINTH EDITION

 Pulsus Decrease
Paradoxu d heart
s sounds

Increased
JVP

Obstruction of
Hypotens
inflow of ion
blood into
ventricles

BRAUNWALD’S Heart Disease Textbook of Cardiovascular Medicine NINTH EDITION

 Clinical • severe, retrosternal, and
Presentation: left precordial
• pleuritic, consequent to
Chest accompanying pleural
inflammation
pain • relieved by sitting up and
leaning forward and
intensified by lying
supine

Harrison’s Principles of Internal Medicine, 19th edition

Clinical
Presentation:

Chest
pain
 Clinical • high-pitched, rasping,
Presentation: scratching, or grating

Friction • 85% cases

rub

Harrison’s Principles of Internal Medicine, 19th edition

 Clinical • Hypotension
Presentation: • soft or absent heart
sounds
Beck’s • jugular venous distention
Triad

Harrison’s Principles of Internal Medicine, 19th edition

 Clinical • Greater than normal (10
Presentation: mmHg) inspiratory
decline in systolic arterial
Pulsus pressure
• Reduced stroke volume
paradoxus • Right ventricular
inspiratory augmentation

Harrison’s Principles of Internal Medicine, 19th edition

 Diagnostic work-up:
• Bacterial
• Neoplastic
• Autoimmune

2015 ESC Guidelines for the diagnosis and management or pericardial diseases
 Laboratory • Acute pericarditis
Testing: • Normal
• Thickened layers
2D - • Pericardial effusion

Echo • Fluid accumulation in

pericardial sac
• Echolucent space

Harrison’s Principles of Internal Medicine, 19th edition

Laboratory
Testing:

2D -
Echo
 Laboratory • Stage 1 : diffuse ST
Testing: elevation
• Stage 2: return to normal
ECG • Stage 3: inverted T wave
• Stage 4: return to normal

• Electrical alternans

Harrison’s Principles of Internal Medicine, 19th edition

Management
Pericarditis?
NO YES
NON-HIGH RISK CASES
NO YES
HIGH RISK CASES

HOSPITAL
ADMISSION
Key Clinical Points
• Requires at least two of the following
• typical chest pain
• pericardial friction rub
• Typical electrocardiographic changes
• pericardial effusion
• Stratification: High-risk vs Non-high risk
• Idioathic vs Tuberculous
• NSAIDS and colchicine (70% - 90%)
• Pericardiocentesis vs cardiac surgery
Acute Pericarditis with moderate
Pericardial Effusion and
resolved Cardiac Tamponade

Left Pleural Effusion