Thursday, August 23rd 2018 VAMR Team 3

CC: 40 M + CP + 2 days HPI: Sudden onset Substernal Episodic Tightness Better with standing Worse with cough or lying down Other: Marathon runner

ROS: +Malaise +Productive cough +Difficulty sleeping Denies fevers, chills, night sweats Denies sore throat, congestion, rhinorrhea Denies SOB, wheezing, hemoptysis Denies orthopnea, PND, palpitations, edema Denies NVD, abdominal pain

PMH: Asthma, OSA, PTSD PSH: None Medications: Albuterol PRN, fluticasone Allergies: NKDA FH: No known CVD SH: 0.5 PPD, no alcohol or IVDU

PAUSE Differential diagnosis part 1

T 97.1 P 62 BP 124/77 96%RA WT 208lb General: Awake, alert, NAD HEENT: NCAT, EOMI, MMM, oropharynx clear Neck: Supple, no LAD, no JVD CV: RRR, nl S1/S2, no m/g/r Pulm: Expiratory wheezes bilat, no respiratory distress, non-cyanotic, no accessory muscle usage Abd: Flat, nd, nt, no rebound, no guarding Extremities: No edema, FROM, intact distal pulses Skin: warm, dry, no rashes Neuro: Nl speech, nl gait, affect appropriate, nl speech

PAUSE Differential diagnosis part 2 Audience requests labs/imaging

Labs WBC 10.6 HGB 16.8 PLT 272 Albumin 4.0 ALT 27 AST 27 ALP 90 Protein 6.7 T-bili 0.9 Ca 9.1 CO2 15 Mg 1.80 Troponin 0.22 CRP 0.6 ESR 13 UDS negative Blood cultures Glucose 95 Na 138 Cl 104 K 4.3 BUN 15 Cr 0.97

NSR 66, T wave inversions in the inferior & lateral leads

Moderate R & small L pleural effusion Impression Moderate right and small left pleural effusions. Right basilar opacification consistent with atelectasis or scarring. Moderate R & small L pleural effusion R basilar opacity c/w atelectasis or scarring

TTE Summary Normal L ventricular cavity size with mild to moderate increased wall thickness. LVEF 55%. I/III diastolic dysfunction. No significant valvular pathology Impression Moderate right and small left pleural effusions. Right basilar opacification consistent with atelectasis or scarring.

PAUSE Differential diagnosis part 3 Audience votes on diagnosis

Acute Viral Myocarditis

Causes Infectious Non-infectious Viruses (adeno, entero, parvo, HCV) Bacterial Mycotic Non-infectious Toxins Hypersensitivity Systemic disorders Radiation

Presentation Variable Exam Subclinical Chest pain Heart failure Cardiogenic shock Arrhythmias Exam M/G/R

Diagnosis ECG – normal, non-specific, arrhythmias, blocks Cardiac biomarkers – negative or elevated CXR – normal, cardiomegaly, pleural effusion Echocardiogram – dilation, WMA, dysfunction CMR – hyperemia, edema, effusion EMB indications: v-arrhythmias, high grade blocks, refractive HF Viral PCR

Treatment Supportive Disorder specific therapy Avoid NSAIDs Heart failure Arrhythmias Avoid NSAIDs Restrict alcohol Reduce exercise for 3-6 months Cleared with exercise test, holter, echo Favorable prognosis NSAIDs do not help, may actually increase mortality