Friday, May 2, 2008


A 25 year old female with a positive PPD who has never been treated for TB presents to your emergency department with chest pain and trouble breathing. When you're taking her blood pressure, something odd happens. You notice the first Korotkoff sound at 110 only during expiration; you don't hear the first Korotkoff sound throughout the respiratory cycle until 95. You notice an elevated jugular venous pressure that does not change with inspiration as well as venous distension of the forehead and scalp. You can barely hear her heart sounds. EKG shows sinus tachycardia with low voltage. You get a CXR and CT.

On the CT, the red arrow points at the myocardium.

Challenge: What's the diagnosis?

Related Questions:
1. What's the blood pressure finding called?
2. What's the absence of JVP change on inspiration called?
3. This represents a triad. What is it?
4. What does the white arrow point to on the CT?

I created the first image (paradox!).
Second image shown under fair use.


Alex said...

1-pulsus paradoxus

4-cardiac tamponade

Craig said...


This is cardiac tamponade. Beck’s triad refers to hypotension, increased JVP, and muffled heart sounds and is characteristics of tamponade. In cardiac tamponade, there is accumulation of pericardial fluid that compresses all the chambers of the heart. The blood pressure finding is called pulsus paradoxus and refers to an abnormally large decrease in systolic blood pressure on inspiration. This is because inspiration increases venous return and results in bulging of the interventricular septum into the left ventricle, reducing preload. Kussmaul’s sign is the absence of an inspiratory decline in JVP. The white arrow on the CT indicates the large pericardial effusion. The CXR demonstrates a markedly enlarged cardiac silhouette.

Sources: UpToDate;; Wikipedia.