Doi:10.1016/j.jen.2005.02.012

Authors: Janna Deason, RN, MSN, CNS, FNP, CEN, BrendaHope, RN, MSN A 23-year-old obese man presents to the emergency Janna Deason and Brenda Hope are staff nurses in the emergencydepartment of McKee Medical Center, Loveland, Colo.
department (ED) with a chief complaint of substernal For correspondence, write: Janna Deason, 200 N Boise Ave, Loveland, chest pressure and dizziness for 2O hours. The pain is a 6 on a scale of 10 and radiates to his back. The patient is diaphoretic, markedly pale, tachypneic, and complaining 0099-1767/$30.00Copyright n 2005 by the Emergency Nurses Association.
of shortness of breath. After triage, the nurse takes the patient immediately to the treatment area and places himon a cardiac monitor. The ED team initiates intravenousaccess with normal saline solution at 100 mL/h and oxygentherapy at 3 L/min by nasal cannula.
The patient had seen his primary care physician and anear, nose, and throat (ENT) specialist the previous day andhad been diagnosed with streptococcal tonsillitis, althoughno laboratory tests were done to confirm this diagnosis.
Medications. The ENT specialist prescribed amoxicillinand clavulanate potassium (Augmentin), but the patientdid not fill the prescription because he could not afford it.
Family history. The patient has no family history of earlycardiovascular disease.
Social history. The patient is a nonsmoker and deniesrecreational drug use.
Skin, head, eyes, ears, nose, and throat. Examinationfound bilateral cervical adenopathy and an erythematouspharynx with bilaterally enlarged exudative tonsils; theneck was supple.
N U R S E P R A C T I T I O N E R / D e a s o n a n d H o p e Chest. Initial vital signs were as follows: pulse, 86 beats/ enzyme levels, the patient has had some type of cardiac min; blood pressure, 98/66 mm Hg; respiratory rate, 40 event. In addition, in spite of the normal findings on the breaths/min; temperature, 37.98C (100.28F); Spo2, 98% chest radiograph, the patient’s abnormal B-type natriuretic on room air. Lungs were clear; heart tones were normal peptide (BNP) level indicates that he is in mild heart without murmur; no jugular venous distention or periph- failure. Furthermore, the erythrocyte sedimentation rate (ESR) indicates that there is an inflammatory componentto his condition. Although the white blood cells (WBCs) typically are elevated with a cardiac event, the degree ofelevation along with the abnormal banding indicate an This patient presents both a diagnostic and a management dilemma. His symptoms are consistent with an acutecardiac event; however, his only risk factor is his obesity.
What additional interventions and diagnostics does His recent medical history suggests an infectious process, possibly causing cardiac complications. Also, despite hisdenial about recreational drug use, a drug-induced cardiac We administer morphine 1 mg intravenously, which event is a possibility. Our initial differential diagnoses relieves the chest pressure, and 2 g of intravenous cef- include a primary cardiac event, drug effect, sepsis, de- triaxone for the infection. An emergency echocardiogram hydration, bacterial endocarditis, viral myocarditis, and reveals a normal ejection fraction and heart valves and no evidence of tamponade. The ED physician consultscardiology, internal medicine, and ENT physicians to What initial interventions and diagnostics does he need? admit the patient to telemetry with an initial diagnosis ofrheumatic fever versus viral myocarditis.
We obtain blood for laboratory analysis (Anelectrocardiogram (ECG) reveals peaked T waves in the anterior leads. The results of a rapid Streptococcus test arenegative. Because the patient has chest pressure, we ad- Results of blood cultures and an antistreptolysin O titer minister 325 mg of aspirin and nitroglycerin 1:150 grains were negative for any bacterial pathogen, effectively ruling sublingually, but the chest discomfort is not relieved. After out rheumatic fever and bacterial endocarditis. The ENT the nitroglycerin is administered, the patient’s blood specialist ruled out epiglotitis. During hospitalization, the pressure drops to 78/44 mm Hg but improves when we patient underwent a cardiac catheterization that again administer 1000 mL of intravenous normal saline solution.
revealed a normal ejection fraction, no valvular pathologic The ED physician interprets the patient’s chest radiograph condition, and normal coronary arteries. His heart failure was treated with furosemide, lisinopril, and carvedilol withgood resolution of symptoms. He continued to receive intravenous antibiotics, and indomethacin for the inf lam-mation. The patient was discharged after 5 days of hos- pitalization with a diagnosis of viral myocarditis. He continued to take the cardiac medications and antibiotics for a few weeks after discharge and was expected to make a Viral myocarditis is an inflammatory disorder of the The results of the diagnostic studies do not readily clarify myocardium. The two most common pathogens are the problem. Clearly, on the basis of his abnormal cardiac N U R S E P R A C T I T I O N E R / D e a s o n a n d H o p e TABLE 1Pertinent abnormal laboratory results CBC, Complete blood count; CPK, creatinine phosphokinase.
adenovirus and enterovirus (eg, Coxsackie virus). Other causative viral agents include influenza, hepatitis A and C, ings on the ECG are nonspecific ST-T wave changes, low human immunodeficiency virus, and cytomegalovirus. The specific virus causing this patient’s myocarditis wasnot identified.
Treatment is aimed at stabilizingthe patient’s hemodynamic condition, the absence of a history of heart disease or cardiac risk factors but with a recent The result of the infection is impaired myocardial functioning resulting from myocyte cell death. This causes and inotropic agents such as digoxin.
myocardial enlargement and increased preload fromvolume overload related to dysfunctional contraction of The most cost-effective test is the echocardiogram, the heart. As this cycle progresses, heart failure develops which usually demonstrates global A biopsy and, without intervention, end-stage cardiac failure and of the myocardium provides a definitive diagnosis, but this is not a first-line test and it would not be performed in The presenting symptoms and history are variable and often are nonspecific. A history of a recent infectious Treatment is aimed at stabilizing the patient’s hemo- illness should provide a clue. This patient’s shortness of dynamic condition, controlling the heart failure, and in- breath, chest discomfort, fever, hypotension, pallor, and creasing cardiac output with standard interventions heart failure are common findings. In addition, his labo- including acetylcholinesterase inhibitors, diuretics, anti- ratory results showed the typical elevations in WBCs, ESR, coagulation based on patient condition, oxygen therapy, and cardiac enzymes. Although his chest radiograph re- and inotropic agents such as digoxin. If the patient requires vealed normal findings, radiographs in 50% of cases of N U R S E P R A C T I T I O N E R / D e a s o n a n d H o p e f luid resuscitation, frequent assessment of lung sounds isvital for early detection of heart failure. A small numberof patients will require cardiac transplantation as a resultof irreversible cardiac damage. If the diagnosis of viralmyocarditis is certain, antibiotic therapy would notbe indicated.
Viral myocarditis is an uncommon but potentially fatal disease. Suspect it in patients with cardiac symptomsin the absence of a history of heart disease or cardiac riskfactors but with a recent infectious illness.
REFERENCE1. Moses S. Myocarditis. 2004. Available from http://www.
fpnotebook.com/CV131.htm. Accessed Aug 2004.

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