Case 31

33 y/o M w/ no significant PMH presents to the ED with c/o not feeling well x1 week. Pt has a history of Percocet use, 3-4 tablets of 10mg/325 daily for about one month which he decided to stop using abruptly on New Year’s Day.  Denies cocaine/alcohol use.  Symptoms include chills, sweats, malaise, nausea.  Patient thought he was withdrawing and went to PMD gave clonidine. He has been taking it twice a day w/o improvement.  He is having trouble sleeping because of feeling restless and anxious, and SOB. Pt thought he was anxious and again attributed his sx to withdrawal; took one dose of Xanax and was able to sleep, but it didn't help with the restlessness.

VS: T 96.5F     P 107       RR 20       BP 119 /75         SPO2 96 RA

REVIEW OF SYSTEMS:
CONSTITUTIONAL: (-) fever, (+) general weakness,
CARDIOVASCULAR: All Negative.
RESPIRATORY: (+) SOB exertion,
GASTROINTESTINAL: All Negative
MUSCULOSKELETAL: All Negative
INTEGUMENTARY: All Negative
NEURO: All Negative

EXAM:
CONSTITUTIONAL: The patient is alert and anxious, NAD.
CARDIOVASCULAR: Rate: Tachycardia. Rhythm: Regular.
RESPIRATORY: Breath sounds clear, no distress present, no wheezing rales, rhonchi or tachypnea. Normal rate and effort.
GI/ABDOMEN: Soft, non-tender, no organomegly, no pulsatile mass. Normal bowel sounds.
MUSCULOSKELETAL/EXTREMITES: Non-tender, normal ROM, no pedal edema or calf tenderness. NVT intact.
NECK: The neck is supple, no JVD, thyromegaly, or lymphadenopathy.
INTEGUMENTARY: Color normal for race, warm and dry, no rash.
NEURO: Oriented x3. Cranial nerves II-XII within normal limits. No motor or sensory deficits.
PSYCH: Oriented x3, mood and affect is normal.

LABS:
CK = 299
Troponin = 0.15; CKMB = 5.6
D-dimer >500
CBC, CMP and coag - WNL

QUESTIONS:

  1. What findings can you see in the EKG below?
  2. What is the differential diagnosis?
  3. What findings are seen on the ultrasound video below?
  4. What minimal quantity of fluid do you need to be able to see these findings?

ANSWERS:

  1. Sinus tachycardia, LBBB
  2. viral myocarditis, drug-induced myocarditis, cardiac ischemia
  3. mild pericardial effusion, moderate pleural effusion, dilated LV
  4. pericardial effusion - 50 mL and pleural effusion - 150 mL
First EKG

First EKG