WBR0560

Author	[[PageAuthor::Hardik Patel, M.D.]]
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Emergency Room
Sub Category	SubCategory::Cardiovascular, SubCategory::Pediatrics
Prompt	[[Prompt::A 14-year-old boy presents to the ER with cough, fever, and malaise for the past 5 days. Since yesterday he has complaints of fatigue, rapid breathing, and breathlessness while walking. On physical examination, he is dyspneic with cyanosis and pedal edema. His HR is 120/min. On cardiac auscultation, gallop rhythm is present and heart sounds are muffled. Peripheral pulses are very difficult to get and jugular venous pressure is raised. Liver is palpable 5cm below costal margin with tenderness. ECG shows low voltage QRS complexes in the limb leads. Diffuse ST segment elevation and T-wave inversion are present. Chest X ray shows massive cardiomegaly with hilar vascular congestion and pulmonary edema. What is the most likely clinical diagnosis?]]
Answer A	AnswerA::Pericardial effusion
Answer A Explanation	[[AnswerAExp::Incorrect: Pericardial effusion usually presents with cough, dyspnea, and chest pain. Chest X ray shows cardiomegaly with "water bottle" configuration of the heart and clear lung fields whereas there is evidence of pulmonary edema in this patient.]]
Answer B	AnswerB::Myocarditis
Answer B Explanation	AnswerBExp::'''Correct:''' See explanation.
Answer C	AnswerC::Endocarditis
Answer C Explanation	[[AnswerCExp::Incorrect: Endocarditis usually involves the heart valves and presents with one or more murmurs. It is mostly seen in rheumatic carditis. Infective endocarditis usually presents with high grade fever with chills, malaise, anorexia, weight loss, dyspnea, cough, and arthralgia.]]
Answer D	AnswerD::Myocardial infarction
Answer D Explanation	[[AnswerDExp::Incorrect: Myocardial infarction is very rare possibility considering the age and clinical presentation of the patient though ST and T-wave changes are suggestive of MI.]]
Answer E	AnswerE::Constrictive pericarditis
Answer E Explanation	[[AnswerEExp::Incorrect: Constrictive pericarditis presents with signs of congestive heart failure as in this case, but has an insidious onset.]]
Right Answer	RightAnswer::B
Explanation	[[Explanation::The most likely clinical diagnosis is myocarditis as the patient has presented with an acute flu-like illness, which is followed by signs of congestive heart failure such as dyspnea, cyanosis, pedal edema, tachycardia, gallop rhythm, tender hepatomegaly, and raised jugular venous pressure. The diagnosis is further supported by chest X ray which shows massive cardiomegaly with hilar vascular congestion and pulmonary edema and electrocardiogram findings of diffuse ST segment elevation and T-wave inversion. Common viruses causing acute myocarditis are coxsackie type A and B, adenoviruses, Epstein-Barr virus, HIV, influenza, measles, mumps, and poliovirus. Educational Objective: References: ]]
Approved	Approved::Yes
Keyword	WBRKeyword::Myocarditis
Linked Question	Linked::
Order in Linked Questions	LinkedOrder::