Question

An elderly patient, female, was admitted to the hospital with breathlessness that was getting progressively worse. She was also experiencing chest pain, ankle edema, swollen arms, legs, and hands. Her physician also noticed new heart murmurs, and a muffled heart sounds due to the muffling effect of fluid surrounding the heart. Her sitting blood pressure was 100/60 mmHg, low volume pulse and rapid breathing.

Her ECG indicated sinus tachycardia with anterolateral Q waves indicating a previous infarction. Chest X-rays indicated cardiomegaly, interstitial edema, and fluid in the lower lungs. Her physician suspects progressive systolic dysfunction after myocardial infarction. Echocardiography showed a dilated heart (left ventricular end diastolic distension [LVEDD]) with apical dilatation, with increased pericardial fluid.

Routine chemistry labs were ordered and the results are as follows:

Sodium	129 mmol/L
Potassium	5.9 mmol/L
Creatinine	157 μmol/L
Urea	9.1 mmol/L
BNP	elevated
Troponin	normal

Questions:

1. Define transudate and exudate.

2. Is this pericardial fluid most likely an exudate or a transudate? Explain your answer.

3. Under what conditions will the physician want to perform a pericardiocentesis to collect the fluid?

4. What condition does the patient most likely have?

Answer 1

1.Transudate results from increased hydrostatic or reduced oncotic pressure. Exudate, on the other hand, is a sign of inflammation and is typically a consequence of increased vascular permeability.

2.Pericardial fluid is not classified into transudate and exudate, thus parameters such as lactate dehydrogenase (LDH) and protein levels are not necessary.

3.Regardless if the pericardial effusion is transudative (consisting of watery fluid) or exudative (made up of protein-rich fluid), a large pericardial effusion causing respiratory symptoms or cardiac tamponade should be drained to remove the excess fluid, prevent its re-accumulation, or treat the underlying cause of the fluid buildup.

4.I feel like the patient is having a pulmonary embolism