Page 1 of 1: Case Discussions #case 1

ajax · Credits: 1237 My Scrapbook My Reading List 10 Books

I was thinking about discussing some very interesting cases I have seen in my brief career. So here I am, starting another new thread (has become a habit now, sorry!), to discuss these unforgettable cases. If you have something interesting, you can also discuss it (start a new thread for each case though, as I think we can have a good discussion on each case in individual threads).

feel free to ask me about more details about the case anytime. I want to awaken the sherlock holmes in you so will be presenting these cases in cryptic format...

This is a case I want you all to diagnose...

57 yr old man, carpenter by profession, presented to medicine em with chest pains. A quick auscultation showed muffled heart sounds, decresed amplitude of sinus rhythm on ecg and pericardial shadowing on routine x ray. Peri-cardial effusion was diagnosed with USG and a USG guided aspiration of fluid showed anaerobic growth. No history of endocarditis, rheumatic heart disease... or any thing at all. In fact he has never been ill through out his life. All immuno markers (even exotic ones) were negative.....

What could be the next investigation or diagnosis...

Note: This case baffled the whole team for about two weeks before we diagnosed him by chance (serendipity).

*sorry mods for discussing medicine here in offbeat... but i wanted the case discussion to be fun. You all can move it to appropriate froum if I am violating the charter here

Larry1981 · Credits: 230 My Scrapbook

Just a lowly medical student here, disappointted that no one here answered. Can you please tell me the progress of this patient?

zolt · Credits: 9209 My Scrapbook My Reading List 40 Books

Well,
It seems to be an interesting case.
With all the immuno markers negative, you have ruled out a wide spectrum of diseases eg:connective tissue disorders, rheumatological disorders, etc.
The ecg is only suggestive of pericardial effusion
At this moment , I would like to rule out
1. valvular disorder: MR(muffled heart sound) - inv. 2D ECHO
2. Thyroid disorder: hypothyroidism -inv.t3,t4,tsh
3. CT Scan chest: ILD-earlier stage not picked up by xray, any mass lesion in the thorax., Extent of effusion, Lymph node status.

note: I suppose , all the routine investigations were carried out and were normal.

zolt · Credits: 9209 My Scrapbook My Reading List 40 Books

In addition knowing the TPR/BP of the patient would be of immense help.And if someone could determine the type of pulse it would be helpful.Well I hope the general and systemic examination of the patient was carried in details.Pericardial fluid was negative for afb's , I suppose.In the mean time symptomatic treatment can be started for the patient for the anaerobic growth.

If the above tests are inconclusive:
1.I would go for BUN/S. Creat.
2.Serum. Cholesterol can be clubbed with TFT's.

zolt · Credits: 9209 My Scrapbook My Reading List 40 Books

Ideally the following is the approach to the patient of pericardial effusion.

a complete medical history taking, physical examination, electrocardiography, chest radiography, echocardiography, and the following laboratory tests: complete blood count; tests of liver function; measurements of blood urea nitrogen, serum creatinine, serum glucose, serum electrolytes, serum triiodothyronine, serum thyroxine, and serum thyroid-stimulating hormone; and tests for rheumatoid factor, antibodies against toxoplasma, antibodies against DNA, and antinuclear antibodies, tuberculin skin tests and tested for tubercle bacilli in sputum or gastric aspirates. search for previous chest films and echocardiograms that might be used to confirm the duration of the effusion.

note:We consider the patients to have large idiopathic chronic pericardial effusion if they meet the following criteria: the cause of effusion not apparent after a thorough evaluation that includes examination of pericardial fluid or tissue, the sum of anterior and posterior echo-free spaces exceeded 20 mm at end diastole.

zolt · Credits: 9209 My Scrapbook My Reading List 40 Books

Though as an ideal physician, you should be unbiased and I am tryimng to do that accordingly.
But since , I have not been provided with the vitals of the patient, I am more tilted towards hypothyroidism at this point of time.
Though my other d/d include:
1. malignancy
2. infection
3. collagen diseases(virtually ruled out)
4. ILD
5. Other endocrine disorder

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