Patient: [Patient Name]
Date: [Date of Encounter]
I. Chief Complaint:
Difficulty breathing, especially when lying down (dyspnea)
Fatigue
Other symptoms (abdominal swelling, leg swelling, weight gain, cough, etc.)
II. History of Present Illness:
Onset and duration of symptoms
Progression of symptoms (worsening, stable)
Functional limitations due to symptoms (activities affected)
Previous episodes of pericarditis (if any)
III. Past Medical History:
Underlying conditions potentially causing pericarditis (tuberculosis, infections, autoimmune diseases)
Previous surgeries (chest trauma, cardiac surgery)
History of malignancy
IV. Social History:
Occupational exposures (potential for TB or other infections)
Travel history (potential for TB or other endemic infections)
V. Medications:
Current medications (diuretics, other medications for heart failure)
VI. Physical Exam:
Vital signs: (BP, HR, RR, Temp)
Jugular venous distention (JVD) – elevated pressure in jugular veins
Kussmaul’s sign – increased inspiratory jugular vein distention (suggestive of constrictive physiology)
Hepatomegaly (enlarged liver)
Ascites (fluid accumulation in abdomen)
Peripheral edema (leg swelling)
Heart exam:
Muffled heart sounds
Pericardial knock (late diastolic sound) – may be present
VII. Diagnostic Studies (consider as appropriate):
Chest X-ray (may show enlarged heart silhouette)
Electrocardiogram (ECG) (electrical abnormalities)
Echocardiogram (TEE – transesophageal echo preferred):
Assess pericardial thickness and stiffness
Evaluate heart chamber filling and function
Cardiac MRI (optional): detailed evaluation of pericardium and surrounding tissues
VIII. Assessment:
Confirmation of constrictive pericarditis diagnosis based on clinical findings and imaging studies.
Severity of constriction (hemodynamic significance)
Potential underlying cause of pericarditis
IX. Plan:
Treatment plan depends on severity and hemodynamic compromise:
Medical management: Diuretics to reduce fluid buildup.
Pericardiectomy: Surgical removal or loosening of the constricting pericardium (definitive treatment).
Balloon pericardioplasty: Minimally invasive procedure to open the pericardium (considered in specific cases).
Address underlying cause of pericarditis if identified (e.g., antibiotics for infection).
Monitor response to treatment with repeat clinical assessments and imaging studies (serial echocardiograms).
Referral to cardiothoracic surgeon for surgical consultation (if pericardiectomy is planned).
X. Prognosis:
Discuss potential for improvement with treatment and the importance of ongoing management.
Address potential complications (heart failure, liver damage, arrhythmias).
XI. Notes:
Include any additional observations or concerns, such as patient’s understanding of the diagnosis and treatment plan, informed consent for procedures, and need for emotional support.
XII. Resources:
Consider providing patient education materials on constrictive pericarditis from reputable sources (e.g., American Heart Association, National Heart, Lung, and Blood Institute).