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Author Aarti Narayan MBBS, Raviteja Reddy Guddeti MBBS
Exam Type USMLE Step 2 CK
Main Category Internal medicine
Sub Category Cardiovascular
Prompt A 65 yr old male patient with chronic renal failure with uremia, on dialysis, presents to the clinic with progressive shortness of breath for the past few months. He also complains of weakness, fatigue and weight gain. Physical examination shows an increased abdominal girth, bilateral pedal edema, hepatomegaly and an increase in jugular venous pressure on deep inspiration. Auscultation revealed an extra diastolic sound. Chest X-ray shows calcification in the precordial area, and EKG showed diffuse low voltage QRS complexes with flattened T waves. What is the best initial therapy in this patient?
Answer A Beta blockers
Answer A Explanation Beta blockers are not indicated in the initial management of constrictive pericarditis.
Answer B ACE inhibitors
Answer B Explanation ACE inhibitors are not indicated in the initial management of constrictive pericarditis.
Answer C Diuretics
Answer C Explanation Diuretics is the correct answer.
Answer D Pericardiocentesis
Answer D Explanation Pericardiocentesis is indicated in the setting of a pericardial effusion.
Answer E Pericardial resection
Answer E Explanation Pericardial resection is the definitive treatment and not the initial therapy.
Right Answer C
Explanation The correct answer is diuretics.This patient has a chronic constrictive pericarditis due to uremia. The diffuse calcification seen on the chest x ray in this scenario is due to the thickened pericardium due to uremic pericarditis. Dietary sodium restriction and diuretics are useful before surgery to relieve the congestive symptoms of constrictive pericarditis and fluid overload. The thickened and calcified pericardium in chronic constrictive pericarditis causes a rise in end diastolic pressures causing pulmonary and systemic congestion. Caution should be maintained while prescribing diuretics as their overuse causes hypotension due to drop in pressures.

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