[amynahmed]

MR.T enters the ER complaining of substernal chest pain, dull in nature. Immediate EKG shows some wave changes, but not specific for a typical myocardial infraction. patient is admitted into ICU, pending results of cardiac enzyme testing.
After one day in ICU, chest pain intensifies, becoming worse with breathing. Heart auscultation reveals a mild rustling or scratching sound near the xiphoid process. he also has a fever now.
After 3 days in ICU, pain is still a problem. Enzyme results prove to be negative- no MI. Heart sounds are now muffled(present but difficult to hear). Patient is in tachycardia due to decreased stroke volume. Jugular vein distension indicates blood is pooling before entering the heart- heart is neither filling or beating well. Blood pressure is falling.

1) Describe relevant anatomy as it may relate to the problem.
2) Diagnosis- (hint:there are 2 problems here- one has led to the other).
3) Make sure and describe why symptoms are occuring
4) Discuss why the patient is now in cardiac distress
5) Dertermine how to treat this life-threatening condition

Thanks in advance
Amy

[imnewtothis]

This sounds like angina which leads to myocardial ischemia.

[AmandaWIRN]

The fever leads me to believe it's pericarditis, which has lead to cardiac tamponade (indicated by the muffled heart sounds). I would expect the physician to do a pericardiocentesis & treat the infection with antibiotics.

[Ricu]

Originally Posted by AmandaWIRN

The fever leads me to believe it's pericarditis, which has lead to cardiac tamponade (indicated by the muffled heart sounds). I would expect the physician to do a pericardiocentesis & treat the infection with antibiotics.

To what Amanda has offered, the pain worsening on inspiration and pericardial friction rub point toward pericarditis as well. Additionally, an echocardiogram should be done before pericardiocentesis to evaluate the effusion and then to facilitate placement of the drain unless it gets done under fluoroscopy. C & S and cytology of the fluid should be done to complete the workup. Indomethicin is usually given for the pain and inflammation.

Interesting case,

R