56/F with C/O Chest pain, generalised weakness.

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56 year old female from Ammanabolu, Tobacco leaf seller by occupation came with chief complaints of Decreased appetite since 20 days, generalised weakness since 15 days ,  Pain abdomen since 10 days. B/L Lower limb ,upper limb edema and facial puffiness since 5 days. She recalled having on and off chest pain since 6 months, pricking type, subsiding on its own, no radiation.

Palpitations + Syncopal attacks -

15 days back patient had loose stools 10-15 episodes per day small in quantity associated with pus, foul smelling, not associated with blood and associated with pain abdomen and fever and nausea and loss of taste  and these lasted for 2 days and relieved after using some medication given by local RMP. After using medication for 3 days she experianced same complaints of diarrhoea which lasted for 2 days 15 episodes per day.

Since then she developed generalised weakness, malaise, fatigue.

SOB since 1 month, gradual in onset, gradually progressed to Grade IV, aggravated on exertion, relieved on rest initially ( not relieving now). No orthopnoea or PND.

Patient also complaining of head ache since 10 days, B/L frontal region, photophobia - , phonophobia - 

Giddiness +

Pain abdomen since 10 days - squeezing type, relieved on taking food, non radiating .

She is not a K/C/O DM - II , HTN.

She is an occasional alcoholic ( beer / whiskey) since 35 years. Chews tobacco leaves daily since 6 months.

O/E:

Patient is C/C

Pallor +

No icterus, clubbing , cyanosis, lymphadenopathy 

No significant pedal edema.

Temp - 98.6 F

PR - 108 bpm

BP - 120/70 mm of Hg

Spo2 - 98 %

CVS - Parasternal heave +

S1 , S2 +

Loud P2 in Pulmonary area.

Pansystolic murmur in Tricuspid area.

Pulsus parodoxus + (12 mm Hg)

Bamberger sign +

Rotch sign +

Raised JVP prominent X descent - 14 cms.

RS - BAE + , fine inspiratiry crepts present in right and left ISA

P/A - distended , multiple hemorrhagic spots seen. Hepatomegaly present with liver span of 15 cm

Tenderness + in epigastric and Right hypochondric area.

Outside Chest X ray:

Out side report as of 14-1-2021 :

Hb - 4.2 gm/dl

Wbc - 7500

Platelet - 1.06 lakhs

Out side 2D echo:

Moderate TR 

Severe PAH

Moderate Pericardial effusion.

 Diagnosis: Severe Anaemia under evaluation with moderate Pericardial effusion with PAH 

Day 1 :

2D echo showed pericardial effusion with Diastolic RV collapse.

Pericardial tap was done and 100 ml was aspirated.

https://youtu.be/bXBvR6P2_D0

Post Pericardiocentesis 

2D echo :

ECG:

After 20 min patient developed Hypotension.                        BP - 60/40 mm Hg

PR - 102 bpm

Patient was given 

1)IVF NS bolus 

2) Inj NorAdrenaline 2amp in 45 ml NS @ 6ml per hour

             ⬇️

BP - 100 /70 mm Hg

1) IVF NS/ RL @ 75 ml/hr

2) Inj NorAdrenaline @ 6ml/hr

           ⬇️

BP - 110/70 mm Hg

ECG :

Diagnosis: Anemia under evaluation (? Hypoproliferative marrow : ?IDA ? B12) with 

Moderate Pericardial effusion (secondary to ?TB ? Malignancy). with

Severe PAH : Type 3 

Rx:

1) Fluid restriction < 1.5 L/ day and salt intake < 2 gm/day

2) Inj Noradrenaline 2 Amp in 50 ml NS (1ml = 80 mcg) @ 4 ml / hr

3) Inj PAN 40 mg/OD

4) Tab MVT /OD

Day 2:

Rx:

1) Fluid restriction < 1.5 L/ day and salt intake < 2 gm/day

2) Inj Lasix 40 mg IV / BD if SBP > 110 mm Hg

3) Inj PAN 40 mg/BD

4) Syp Sucralfate 10 ml TID 20 min before food.

5)Tab Orofer XT OD

6) Inj Hydroxycobalamin 1000mcg in 100 ml NS IV OD

7) Tab Folvite 5 mg OD

Day  3:

Pericardial fluid cell count:

TC - 400 cells

DC- 80%neutrophils 

20%lymphocytes

RBCs - plenty

Rx:

1) Fluid restriction < 1.5 L/ day and salt intake < 2 gm/day

2) Inj Lasix 40 mg IV / BD if SBP > 110 mm Hg

3) Inj PAN 40 mg/BD

4) Syp Sucralfate 10 ml TID 20 min before food.

5)Tab Orofer XT OD

6) Inj Hydroxycobalamin 1000mcg in 100 ml NS IV OD

7) Tab Folvite 5 mg OD

8) Inj Ceftriaxone 1g IV BD

Bone marrow aspiration and biopsy was done.

Day 4:

Pericardial fluid ADA - 9

CBNAAT of pericardial fluid- negative.

Diagnosis: Anemia under evaluation (? Hypoproliferative anaemia) with 

Moderate Pericardial effusion (effuso constrictive) secondary to ?Malignancy ( ?Multiple myeloma ? Lung)

With denovo hypothyroidism.

Rx:

1) Fluid restriction < 1.5 L/ day and salt intake < 2 gm/day

2) Inj Lasix 40 mg IV / BD if SBP > 110 mm Hg

3) Inj PAN 40 mg/BD

4) Syp Sucralfate 10 ml TID 20 min before food.

5)Tab Orofer XT OD

6) Inj Hydroxycobalamin 1000mcg in 100 ml NS IV OD

7) Tab Folvite 5 mg OD

8) Tab Thyronorm 25 mcg OD

9) Inj Ceftriaxone 1g IV BD

Day 5:

HRCT chest :

Plasma cells noted in bone marrow imprint.

Rouleaux formation in peripheral smear.

Rx:

1) Fluid restriction < 1.5 L/ day and salt intake < 2 gm/day

2) Inj Lasix 40 mg IV / BD if SBP > 110 mm Hg

3) Inj PAN 40 mg/BD

4) Syp Sucralfate 10 ml TID 20 min before food.

5)Tab Orofer XT OD

6) Tab Folvite 5 mg OD

7) Tab Thyronorm 25 mcg OD

8) Inj Ceftriaxone 1g IV BD

Pericardial fluid cell block:

Bone marrow biopsy:

Patient was referred to higher centre in view of oncological intervention.

The patient’s course of treatment at the onco center was followed