Author: Melanie Dyer / Editor: Steve Corry-Bass / Codes: CC11, CP1, CP2, CP4, GP1, ResP1, SLO1, SLO3 / Published: 07/10/2020

A 57-year-old female presents with a history of being unable to exert herself when rushing for a bus with associated heavy central chest pain 5 days earlier. Over the subsequent days the chest pain persisted and she developed, exertional breathlessness, palpitations, epigastric pain radiating to her back and on the day of presentation to ED she had two syncopal episodes. She has a PMH of Hypertension and denies any recent illnesses.

On examination, she looks pale and unwell with a labile BP between 70-90 systolic; Her remaining observations were normal. She has a scattered wheeze bilaterally and guarding in the epigastrium and right upper quadrant with localised peritonism and Murphy’s sign is  positive.

Initial Investigations:

ECG – ST elevation 1mm inferiorly and laterally

VBG: pH 7.289 [7.35-7.45], pCO2 6.14 [4.67-6.4], HCO3 19[19-28] lactate 5.7[0.5-1.6]

CXR – no consolidation.

Bloods:

High Sensitivity Troponin – 5 [0-3 negative; 4-120 moderate; >120 positive)

D dimer 21000 [0-500]

K+ 6.2 [3.5 -5.3]–  Prescribed treatment for hyperkalaemia

A CTPA is requested based on raised D-dimer to rule out PE. CT abdomen ordered for a suspected abdominal visceral perforation or cholecystitis. CT Findings: 1. 2.5cm pericardial effusion 2. hepatic engorgement 3. Right heart strain 4. Right lung mass.

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