A 56-Year-Old Man With Flu-Like Symptoms Presents With Palpitations

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The patient experiences a 12 mm Hg drop in systolic blood pressure on inspiration and a heart rate of 132 bpm.
The patient experiences a 12 mm Hg drop in systolic blood pressure on inspiration and a heart rate of 132 bpm.

Case

A 56-year-old man who previously felt well reports that flu-like symptoms developed the previous week associated with rhinitis, sneezing, nonproductive cough, and malaise. He did have some low-grade fevers that have now subsided. He went to an urgent care center, where he was told he had a cold and was treated with over-the-counter cold medications containing ibuprofen and pseudoephedrine.

He presents to the office urgently because, although his rhinitis and cough have improved, he feels worse. He reports marked shortness of breath and palpitations. On physical examination, he appears tachypnic with a respiratory rate of 25 bpm. His heart rate is 132 bpm and his blood pressure is 88/54 mm Hg. There is a 12-mm Hg drop in his systolic blood pressure on inspiration. On auscultation, his lungs are clear bilaterally, with distant heart sounds on examination. No rubs or gallops are heard. There is jugular vein distention to his earlobes on examination, and his extremities are cool and clammy.

Laboratory tests show a white blood count of 13,700, but the remainder of the results are normal. An electrocardiogram shows low voltage with electrical alternans.

What is the next best step for this patient while in the office?

A. Immediate transfer to the hospital for pericardiocentesis; consider administering intravenous fluids while waiting for emergency transportation to arrive

B. Decrease the doses of his blood pressure medicines and have him come back in a week to see whether his symptoms have improved and blood pressure has increased

C. Refer him for an outpatient echocardiogram

D. Start him on steroids and beta-agonist therapy to help with the shortness of breath

E. Admit to telemetry for intravenous furosemide and get a 2-dimensional echocardiogram to rule out congestive heart failure

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