CPC

RHAFFY B. RAPACON

DATA:
A 67-year-old overweight man

HISTORY OF PRESENT ILLNESS

Two months history of shortness of breath, a nonproductive cough, and bilateral swelling of the lower extremities. He also reported a tight sensation in the neck, occasional wheezing, and an increase in dyspnea after meals. The patient noted the onset of symptoms soon after a hunting trip in November. He had no other constitutional symptoms and had

not ingested or had contact with anything unusual

during his trip.

HISTORY OF PRESENT ILLNESS

Because of worsening respiratory symptoms, the patient was admitted to a local medical center. At the time of his admission, he had a nonproductive cough and was able to walk only a short distance without stopping, because of dyspnea. He reported orthopnea but not paroxysmal nocturnal dyspnea.

PAST MEDICAL HISTORY Gastroesophageal reflux and a remote

pneumonia.
No history of lung or heart disease,

occupational exposure, allergies, or

tobacco use.

PHYSICAL EXAMINATION
afebrile blood pressure - 150/86 mm Hg, his heart rate - 110 beats per minute respiratory rate - 28 breaths per minute weight - 109 kg, with a body-mass index - 34.4 kg

PHYSICAL EXAMINATION Lung demonstrated scattered, brief expiratory wheezes in both lungs. Heart jugular venous pressure could not be visualized. heart sounds were distant, with no audible murmur, rub, or gallop. Extremities lower extremities had symmetric,pitting edema (2+).

DIAGNOSTIC PROCEDURE Blood Tests, Electrolytes, Kidney Function Tests, Liver Function are all normal Increased in Blood Glucose Increased in Alkaline Phosphatase

DIAGNOSTIC PROCEDURE
A chest radiograph showed cardiomegaly and mildly increased pulmonary vasculature. An electrocardiogram showed sinus tachycardia at a rate of 110 beats per minute with diffuse T-wave

inversions and low voltage.

Hilar, subcarinal, and pretracheal lymph nodes that were small and calcified and a small right-sided pleural effusion were noted

DIAGNOSTIC PROCEDURE
A transthoracic echocardiogram showed normal left ventricular size and function. The right ventricle was mildly thickened but not enlarged or hypocontractile. The aortic valve was thickened, with no stenosis or regurgitation. There was no other valvular abnormality.

PULMONARY FUNCTION TEST

TEST
forced vital capacity (FVC)

RESULT
59 percent of the predicted value

NORMAL VALUES >80% of predicted volume

forced expiratory volume

65 percent of the predicted value

>80% of predicted volume

ratio of FEV1 to FVC

76 percent

>80%

forced expiratory flow

54 percent of the predicted value

85 percent of the predicted value 77 percent of the predicted value

>50%

total lung capacity

residual volume

DIAGNOSTIC PROCEDURE
high-resolution CT scan of the chest : show a thickened pericardium. rightheart. and left-heart catheterization showed

increased in pressure in right and left side of the

Result mean right atrial pressure right ventricular pressure pulmonary-artery pressure 20mm Hg

normal 6 mm Hg

48/20 mm Hg

2030 mm Hg (systole) <5 mm Hg ( diastole) 2030 mm Hg(systole) 815 mm Hg(diastole)

48/22 mm Hg (mean pressure, 30 mm Hg)

left ventricular pressure

130/20 mm Hg

140 mm Hg (systole) 812 mm Hg(diastole)

140 mm Hg (systole) 90 mm Hg (diastole)

aortic pressure

130/80 mm Hg

DIAGNOSTIC PROCEDURE
Simultaneous right and left ventricular diastolic pressures showed equalization and a dipandplateau waveform of pattern; simultaneous pressure measurements ventricular systolic

showed discordance, a finding that is consistent with increased ventricular interaction.

PERICARDIECTOMY:
Inspection of the pericardium revealed dense thickening of nearly 10 mm in regions. Pericardiectomy without cardiopulmonary bypass was performed with resection of the anterior pericardium between the right and left phrenic nerves and from the great arteries superiorly to the

diaphragm inferiorly.

DISCUSSION

CARDIAC

Shortness of breath,
HEPATOBILLIARY

nonproductive cough, swelling of the lower extremities

PULMONARY

NEPRHO

PULMONARY:
Shortness of breath nonproductive cough

occasional wheezing
gastroesophageal reflux and a remote pneumonia. A chest radiograph : mildly increased pulmonary

vasculature, increased interstitial markings with possible

septal lines Spiral CT scanning of the chest: Hilar, subcarinal, and

pretracheal lymph nodes that were small and calcified

and a small right-sided pleural effusion were noted

 Abnormal pulmonary testing

CARDIAC :
obesity Bilateral swelling of the lower extremities

tight sensation in the neck

able to walk only a short distance without stopping Orthopnea blood pressure was 150/86 mm Hg heart rate was 110 beats per minute

body-mass index of 34.4 kg

A chest radiograph : cardiomegaly

 Electrocardiogram: sinus tachycardia at a rate of 110 beats per minute with diffuse T-wave inversions and low voltage. transthoracic echocardiogram : right ventricle was mildly thickened but not enlarged or hypocontractile.

The aortic valve was thickened

right- and left-heart catheterization: increased in pressure

Pericardiectomy: pericardium revealed dense

thickening of nearly 10 mm in regions,

 Histologic examination of the pericardium revealed

fibrosis with granulomatous inflammation. Stains and cultures for bacteria, fungi, viruses, and acid-fast bacilli were negative

Final Diagnosis

Pleural effusion secondary to Class III CHF due to constrictive pericarditis.