S:

94 y/o F, with a PMHx of CHF, CKD, HTN, CAD, pre-DM and infrarenal abdominal aneurysm, who presented to the thoracic clinic after an echo from seven days prior revealed a large pericardial effusion. Patient did not follow up with the clinic earlier due to COVID concerns. She was sent to the ED from the thoracic clinic for admission. Upon admission, patient has no complaints. She denies fever, chills, shortness of breath, chest pain, palpitations, cough, syncope, dizziness, nausea, vomiting or abdominal pain.

PMHx: CHF, CKD Stage 4, HTN, CAD, pre-DM, infrarenal abdominal aneurysm, hard of hearing, constipation

PSx: none

Medications: Tylenol 500mg PO PRN (twice daily), Amlodipine 10mg PO daily, Labetalol

100mg take two tablets (200mg) PO twice daily, Losartan 100mg PO daily, Omeprazole 20mg PO daily, Sodium bicarbonate 325mg 2 tablets PO twice daily, Docusate sodium 1 capsule (100 mg) three times a day PO PRN

Allergies: NKDA

Social history: Denies alcohol, tobacco or drug use. Lives with family at home and uses a walker.

O:

Vital Signs: T 97.9, HR 63 bpm, RR 13 breaths/minute, BP 160/85, Ht 5’3”, Wt 125 lbs, BMI 20.80 kg/m2

Physical Exam:

General: alert and oriented, no acute distress, well-nourished, cooperative

HEENT: normocephalic, atraumatic, no icterus or pallor, moist mucous membranes

Neck: JVD present

CV: regular rate and rhythm, muffled heart sounds

Pulm: CTA, no respiratory distress

Abd: soft, nontender, nondistended

Ext: bilateral LE edema 2+

Labs:

6.5 | 46.3 | 176                      141 | 104 | 22  105

         14.6                                 5.0     24    2.03

Troponin: 0.023

aPTT 29.3, PT 12.1, INR 1.03

COVID-19: Negative

24 hour I/O: Intake 600 mL, Output 250 mL, Net 350 mL

CXR: Cardiac contour enlarged, and pericardial effusion must be considered. Evidence of significant pleural changes or pleural effusions bilaterally, worse on the left. No large dense consolidations. There may be mild atelectasis or consolidative changes at the lung bases.

Echo 2/11/21: severely elevated central venous pressure (11-20 mmHg), IVC dilated consistent with elevated RA pressure, large pericardial effusion present, mildly dilated left atrium, mildly increased left ventricular wall thickness, mild LVH, LV EF 60%, normal right systolic function, mild RVH

EKG: Sinus bradycardia at 54 bpm, RBBB

A:

94 y/o F, with a history of CHF, CKD, HTN, CAD, pre-DM and infrarenal abdominal aneurysm, with a large pericardial effusion revealed on echo seven days ago.

P:

Schedule subxiphoid pericardial window creation with pericardial biopsy and catheter placement for tomorrow (2/19/21)

NPO at midnight 

Preop labs [Coags, type and screen]

DVT prophylaxis with SCD