peter90036
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40yo man had some cough some fatigue, now has chest pain since this morning, he says chest pain feels better when he leans forward. You notice bulging neck veins. You take his BP 140/90, and when he takes a breath 130/90.
What do you do next ? (for usmle)
A. ECG
B. Cardiac echo
C. Pericardiocentesis
D. CXR
E. Chest tube
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| nyimalay
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A
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| Justice
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B. Cardiac echo followed by C. Pericardiocentesis
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| aspire
Forum Senior
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Pulsus paradoxsus...Cardiac tamponade..Emergency..pericardiocentesis.
Ans: Pericardiocentesis.
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| nyimalay
Forum Elite
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I think peter set this question.
I just didn't want to miss MI.
Please post correct answer or I should follow Justice's?
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| heartblock
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It's not cardiac tamponade...BP 140/90 and 130/90
so Echo then pericardiocentesis?
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| sandra
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pericarditis..echo
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| maddoc-brasco
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uhmmm, lemme think... POSITONAL chest pain in a quite stable patient, pp, jvd, no hTN.. maybe pericarditis (effusional maybe).. should we do an echo BEFORE stucking a huge needle in his chest?
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| maddoc-brasco
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by the way, since the question is "What do you do next ?" and not "what is the best next step in the management of this patient's pahology?" EKG is the answer, rule out MI first, ekg is inexpensive fast and everybody that steps in to the hospistal get one! 
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| peter90036
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no hTN = no acute tamponade, not enough to compromise CO
pulsus paradoxus isnt specific
could still be an MI
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| arlete
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EKG.
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| liliaeliz
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the next best test is ekg roule out other causes the chest pain ,but i think that has a pericarditis
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| arlete
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Now YOU r the cute one, peter...!
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| Markus2009
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A--------> rule out MI first
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| DrVirgo
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He isn't in shock so it isn't an emergency. -you can hold off on the pericardiocentesis in case you think it could possibly be pericardial tamponade.
"worse when you lean back, and better when you lean forward" could indicate Pericarditis (due to the stretch on the pericardium)
First step in Chest Pain though is to start out with an EKG.
So I pick A. ECG
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| solitarius
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Thank you Arlete,
I am agree........EKG is the best initial step(because2-3% of the times an MI pain could be positional)....cheap,easliy done and read anywhere and VERY informative.After that ECHO and then suck the fluid out if any......or put a peicardial window...
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