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Would it be legally protective to do a bedside ultrasound if you are unable to save your images anywhere? Would documenting the findings in the note be sufficient?
better to do the US even if you cannot save images (though that is preferable) as some of that is for billing. Always patient safety first so I do rec doing what is best for the patient (which will then usually roll onto med legal) w the caveat that a normal US does not rule out myocarditis...
not sure how tachycardia helps you here. The fever it self could give a HR of 116.
Agree, probably not too helpful. Would be ideal if MDM at least mentioned why presentation was not concerning for things like PE or peri/myocarditis... tachycardia with chest pain should at least be addressed but do not always require a huge work up. Thank you for listening!
Troponins can be and are often elevated in pericarditis as well. Troponins can be negative in early myocarditis. You cannot differentiate myocarditis with pericarditis using troponins alone.
While it is true that troponins can be negative in early myocarditis, troponins are not elevated in pericarditis. It is often difficult to differentiate the two because they may coexist together (perimyocarditis and myopericarditis). ECG, troponin, cardiac monitoring, and history can be helpful but the diagnosis of myocarditis can be extremely difficult. The CorePendium chapter on Myopericardial Diseases is an excellent resource.
Perhaps we could advise that troponins may only be mildly elevated in pericarditis. For reference: https://www.sciencedirect.com/science/article/pii/S0735109703013093?via%3Dihub
Thx for sending, interesting info!!M
I believe with elevated trop we would more accurately use the term myopericarditis. CorePendium has an awesome chapter on this and authors point out that that the two often exist in a continuum. I think chapter authors Drs Farzad and Moleno would be a great resource for further questions on this topic. They can be contacted through an embedded chapter link. Thanks for listening and being engaged!
Thank you for sharing this case. It's challenging even in a well-done segment such as this to capture all the elements of the case. I listened twice and what lingers with me is - what did the patient look like (e.g zero distress or unwell and pale), what was the exact documented history (e.g. was it an occasional little cough or a persistent cough?) and physical exam (let's assume there is nothing more than what was mentioned). With a fever of 38.9, a HR of 116 is not surprising. What might have changed this outcome? a) an EKG with anyone with chest pain, might have changed the course, b) a dimer is fraught with problems here, since PE was not the problem and would have been falsely elevated, leading to a CT chest which might not have changed much - but would have created a second chance to examine this patient. But if I'm unimpressed by the cough and cold sx then I probably would have gotten the dimer. c) to be honest, I have a low-threshold to get a troponin on pretty much anyone with chest pain. It's easy to play Monday morning quarter-back, but say the cough was not really much - I'd end up getting a CXR, ekg, dimer and troponin. Lastly, it cannot be said enough how the discharge advise in a simple form is important.
What you do matters.