1. Thursday, August 23rd 2018 VAMR Team 3

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

3. 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

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

5. PAUSE
Differential diagnosis part 1

6. T P BP 124/ %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

7. PAUSE
Differential diagnosis part 2
Audience requests labs/imaging

8. 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

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

11. 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

12. 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.

13. PAUSE
Differential diagnosis part 3
Audience votes on diagnosis

14. Acute Viral Myocarditis

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

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

17. 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

18. 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