HPI:

43F with a history of HTN and diastolic heart failure presenting with two days of shortness of breath. Reports that symptoms are worse at night when lying down to sleep and associated with a cough productive of white sputum. She also reports intermittent left-sided chest pain, described as sharp and exacerbated by cough or deep inspiration. She denies fevers/chills, nausea/vomiting, sick contacts or recent travel.
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Physical Exam:

VS:	T	98.2	HR	81	RR	19	BP	219/91	O2	95% RA
Gen:	Adult female in no acute distress, alert and responding appropriately to questions.
HEENT:	PERRL, EOMI, mucous membranes moist.
CV:	RRR, no murmurs appreciated, no JVD.
Lungs:	Crackles at right lung base.
Abd:	Soft, non-tender, non-distended, without rebound/guarding.
Ext:	1+ pitting edema in bilateral lower extremities to knee.
Neuro:	AAOx4, grossly normal peripheral sensation and motor strength.

Labs/Studies:

• Troponin: 0.15
• Procalcitonin: 0.15
• CBC: 10.9/9.1/26.4/296
• BMP: 134/4.6/104/22/56/2.87/214

Imaging:

• CXR: Consolidation involving the majority of the right lung, cardiomegaly.
• Bedside Echo: LVEF 55%, concentric LVH, no wall motion abnormality, moderate pericardial effusion noted, RV not collapsed.

Assessment/Plan:

43F with a history of HTN, diastolic heart failure presenting with SOB.

#SOB: CXR finding of right-sided consolidation with history of productive cough, evidence of leukocytosis with neutrophil predominance, and relative hypoxemia suggestive of community-acquired pneumonia. No evidence of systemic inflammatory response. PE unlikely, patient is not bed-bound and alternative diagnosis more likely.
– Start empiric antimicrobial therapy ceftriaxone 1g IV q24h, azithromycin 500mg IV q24h.

#Pericardial Effusion: Noted on bedside echo, no evidence of RV collapse to suggest cardiac tamponade. Also, no JVD and pulsus paradoxus measured at 8mmHg.
– Obtain formal transthoracic echocardiogram to evaluate effusion.
– Consult cardiology if worsening hemodynamics

#Elevated Troponin: No ECG changes suggestive of acute ST-elevation MI. May represent NSTEMI though historical features not consistent with ACS.
– Trend troponin/EKG q.8.h. x3
– Give aspirin 325mg, consider anti-coagulation.
– Consider stress echo prior to discharge

#Elevated Creatinine: Baseline unknown, likely acute component with or without chronic kidney disease.
– Volume resuscitation as tolerated, follow repeat chemistry.

#Hypertension: Asymptomatic, resume home medications.

Physiology of Cardiac Tamponade ¹

• Intrapericardial pressure (IPP) normally reflects intrathoracic pressure (ITP).
• Inspiration: low ITP → low RAP → increased RA filling.
• Expiration: high ITP → low LAP → increased LA filling.
• Increased pericardial fluid → increased IPP → increased LA/RA filling pressures (diastolic dysfunction) → increased variation with respiration.
• Earliest hemodynamic change in cardiac tamponade is JVD or IVC dilation.

IVC variation as marker for RAP ¹

IVC Diameter (cm)	Change with Respiration (%)	RAP (mmHg)
<2.1	>50%	0-5
<2.1	<50%	5-10
>2.1	>50%	5-10
>2.1	<50%	>15

Grading Pericardial Effusions ¹

Grade	Echo-free space (mm)	Size (mL)
Small	<10	100
Moderate	10-20	100-500
Large	>20	>500

History and Physical Exam in Patients with Acute Pericarditis ^2,3

Symptom/Sign	ACS	Pericarditis	PE
Quality	Pressure	Sharp	Sharp
Pleuritic	No	Yes	Yes
Positional	No	Yes (worse when supine)	No
Duration	Minutes to hours	Hours to days	Hours to days
Improves with NG	Yes	No	No
Friction Rub	No	Yes	No
S3	Maybe	No	No

Differential Diagnosis of Pericardial Effusion ^2-8

References:

1. Schairer, J. R., Biswas, S., Keteyian, S. J., & Ananthasubramaniam, K. (2011). A Systematic Approach to Evaluation of Pericardial Effusion and Cardiac Tamponade. Cardiology in Review, 19(5), 233–238. doi:10.1097/CRD.0b013e31821e202c
2. Khandaker MH, Espinosa RE, Nishimura RA, et al. Pericardial Disease: Diagnosis and Management. Mayo Clinic Proceedings. 2010;85(6):572-593. doi:10.4065/mcp.2010.0046.
3. Lange, RA, Hillis, LD. Clinical practice. Acute pericarditis. The New England journal of medicine. 2004;351(21), 2195–2202. doi:10.1056/NEJMcp041997
4. Imazio M, Adler Y. Management of pericardial effusion. Eur Heart J. 2013;34(16):1186-1197. doi:10.1093/eurheartj/ehs372.
5. LeWinter MM. Clinical practice. Acute pericarditis. N Engl J Med. 2014;371(25):2410-2416. doi:10.1056/NEJMcp1404070.
6. Vakamudi S, Ho N, Cremer PC. Pericardial Effusions: Causes, Diagnosis, and Management. Prog Cardiovasc Dis. 2017;59(4):380-388. doi:10.1016/j.pcad.2016.12.009.
7. Imazio M, Mayosi BM, Brucato A, et al. Triage and management of pericardial effusion. J Cardiovasc Med (Hagerstown). 2010;11(12):928-935. doi:10.2459/JCM.0b013e32833e5788.
8. Maisch B, Seferović PM, Ristić AD, et al. Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European society of cardiology. Eur Heart J. 2004;25(7):587-610. doi:10.1016/j.ehj.2004.02.002.