Cardiology Department

Medical Faculty
Hasanuddin University

Case Report
2013

PERICARDIAL EFFUSION

Present by:
Sharifah Faseha
Supervisor:
dr. Abdul Hakim Alkatiri, SpJP.FIHA

PATIENTS IDENTITY
Name
Age
Registration no
Date of admission

: Mrs J
: 35 years old
: 53.83.18
: 25th April 2013

History Taking
Chief complaint: Shortness of breath
Further anamnesis: It was felt since 3 days
before she was admitted to the hospital.
Dyspnea (+), DOE(+), PND (+), Orthopnea(+),
chest pain(+) occur along with SOB.nausea(-),
vomiting (-), fever(-) Urination and defecation
were normal.

History of past illness

History of hypertension (-)

History of Diabetes Mellitus (-)
History of heart disease (-)
Family history of heart disease (-)
History of breast cancer (+) undergone total
right mastectomy

Clinical Examination
General condition:
moderate illness/ normal weight/ conscious
Vital Sign
BP: 120/80 mmHg
R : 26x/min
HR: 88 bpm
T : 36,8oC (afebrile)
Head: anemia (-), jaundice (-)
Neck: JVP R+3cm H20
Lung: BS: bronchovesicular
Rh -/- basal
Wh -/-

Clinical Examination
Cardiac Examination
Inspection : Ictus cordis wasnt visible
Palpation
: Ictus cordis wasnt palpable.
Percussion : Right heart border in right
parasternalis line, left heart border one finger
from left midclavicle line ICS V.
Auscultation : Heart Sounds = S I/II regular.

Clinical Examination
Abdominal Examination
Inspection
Auscultation
Palpation
Percussion

: Flat, following breath movement

: Peristaltic sound (+), normal
: Liver and spleen are unpalpable
: Tympani (+)

Extremities
Oedema pretibial -/ Oedema dorsum pedis -/ Cyanosis (-), Clubbing finggers (-)

Electrocardiogram on 25th April 2013

ECG Interpretation

Rhythm
HR / QRS rate
Axis
Regularity
P wave
PR interval
QRS complex
ST segment
Conclusion

: Sinus Rhythm
: 100bpm
: Normoaxis
: Regular
: 0,08 s
: 0,12 s
: 3 small squares (0,12 s)
: Normal
: Sinus rhythm, HR 100bpm, normoaxis

Laboratory Findings
Test

Result

Normal Value

WBC

7,75 [10^3u/L]

4,0 10,0

RBC

4,38 [10^6u/L]

4,0 6,0

HGB

11,4 [g/dL]

13,0 17,0

HCT

35,9 [%]

40,0 54,0

PLT

309 [10^3u/L]

150 - 500

Ureum

14 [mg/dL]

10 - 50

Creatinine

0,6 [mg/dL]

M(<1,3) F(<1,1)

SGOT

18 u/I

<38

SGPT

5 u/I

<41

Within normal limit

Chest X-Ray
Duplex pulmonary
tuberculosis
Cardiomegaly with
dilatation of aorta

Echocardiogram

Echocardiogram description

Good LV systolic function. EF 81%

Hyperkinetic
RA.RV collapse
Heart valves : Mitral: Good function and movement
: Aorta : 3cuspis. Calcification (-).
Good function and movement
: Tricuspid : Good function and
movement
: Pulmonal : Good function and
movement
Conclusion : Impending cardiac temponade

Working Diagnosis
Pericardial Effusion

Therapy
IVFD Nacl 0,9% 500cc
Ceftriaxone 2gr/24hrs/iv (antibiotic)
Pericardiocenthesis

Planning
Cytology analysis of pericardial fluid

PERICARDIAL EFFUSION

DISCUSSION

Pericardium
Fibrous sac surrounding heart-dense network of
collagen fibres
Serous membrane two continuous layers
separated by a small amount of fluid lubricant (3050mls straw coloured (serous fluid))
Layers are called visceral and parietal
Visceral is inner layer (epicardium)
Parietal is continuous with diaphragm and outer walls of
great arteries

Surrounds the heart

Continuous with the great arteries and the
diaphragm

What is its function?

Stabilises the position of the heart within the
chest
Prevents friction between the moving heart
and adjacent structures

Pericardial effusion
Pericardial effusion ("fluid around the heart")
is an abnormal accumulation of fluid in
the pericardial cavity. Because of the limited
amount of space in the pericardial
cavity, fluid accumulation leads to an
increased intrapericardial pressure which can
negatively affect heart function.

Causes

Infective (viral or bacterial)

Following a myocardial infarction or cardiac surgery
Radiation therapy
Neoplastic disease (commonly lung or breast)

Pathophysiology
Inflammation of pericardium due to infection
metastasis process or lymphatic obstruction
Disturb the equilibrium between the production and
re-absorption of pericardial fluid
Pericardium exude fluid, fibrin, blood cells.

Increases fluid volume in pericardial space

Pericardial effusion

Investigations and clinical signs

Clinical examination SOB, orthopnoea, tachycardia
(varying degrees)
Auscultation may have muffled heart sounds
ECG may show low amplitude QRS complexes and
alternating axis
CXR globular appearance to heart and therefore
increased cardiothoracic ratio
Echo size of effusion and haemodynamic effect of it

CXR
Being describe as
water bottle heart
shape
Widening of cardiac
sillhoutte

Echocardiogram

Treatment
Depends on the underlying cause and the severity of the
heart impairment.
If the pericardial effusion is due to a condition such as lupus,
treatment with anti-inflammatory medications may help.
If the effusion is compromising heart function and causing
cardiac tamponade, it will need to be drained, most
commonly by a needle inserted through the chest wall and
into the pericardial space called pericardiocentesis.
In some cases, surgical drainage may be required by cutting
through the pericardium creating a pericardial window, which
allows ongoing drainage of fluid externally or internally such
as into the pleural cavity

Additional info
Pericardial effusion develops in 5% to 15% of patients with
cancer and is sometimes the initial manifestation of
malignancy.
Most pericardial effusions in cancer patients result from
obstruction of the lymphatic drainage of the heart
secondary to metastases.
The typical presentation is that of a patient with known
cancer who is found to have a large pericardial effusion
without signs of inflammation.
The most common malignant causes of pericardial
effusions are lung and breast cancers, leukemias
(specifically acute myelogenous, lymphoblastic, and chronic
myelogenous leukemia [blast crisis]), and lymphomas.