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
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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
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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.
Veterinary Research Communications , 31 (2007) 931–939DOI: 10.1007/s11259-007-0009-4 Salmonellae and Campylobacters in Household and Stray Dogs in Northern Taiwan H.-J. Tsai1 , 2 , ∗, H.-C. Huang1 , 2, C.-M. Lin1, Y.-Y. Lien3 and C.-H. Chou11 Department of Veterinary Medicine and 2 Center for Zoonoses Research, College ofBioresources and Agriculture, National Taiwan University, Taipei; 3
The Lasting Effects of Using Auricular Acupuncture to Treat Combat-related PTSD: A Case Study By Greg Golden, MSOM, DiplOM (NCCAOM), LAc AbstractPost-traumatic stress disorder (PTSD) is a condition of certain psychological symptoms occurring long Greg Golden , MSOM, DiplOM (NCCAOM), LAc was trained in the NADA protocol at the Lincoln Recovery term after a traumatic event or series of such