CASE REPORT

• 46yo male sent to ED as a result of having a routine pre-op ECG at a pathology laboratory organised by his GP which showed some non-specific changes on a background of a mild electric shock 5/52 earlier which he did not have LOC nor seek medical attention. Patient discussed by the GP with a Cardiologist for patient to attend ED and for a possible echo.
• We don’t have an echo service at our small hospital (neither GP or Cardiologist rang us to discuss the patient) but I happened to be on duty when the patient arrived after driving himself to hospital
• Patient had slurred speech and a PEG due to resection 10 months earlier of an oral cavity cancer by ENT and plastics at the nearest tertiary centre. 
• There was more surgery planned so he was asked to have a pre-op ECG.
• Not having radioRx or chemoRx.
• Feeling well, not dizzy or SOB and no current chest pain.
• Reported intermittent brief nocturnal bilateral anterior chest pain and separately intermittent left anterior neck pain in last 5/52 since electrocution.
• Well-looking  SBP 120  HR 100 SR  no respiratory distress O2sat 97% on air.
• Afebrile, no evidence of DVT.
• ECG: ST elevation V3-V4 (but V4 alone was elevated on ECG at path 4hrs earlier), istat Trop I/U&E/Cr: NAD
• Decided to do a focussed cardiac US in case he had a pericardial effusion.

• Using my GE Vscan showed a large pericardial effusion causing slight RA free wall collapse, with a large RV mass occupying ¾ of RV cavity with slight MR and a distended IVC. No flow in the mass but appears to be a tumour rather than clot.
• Discussed with Cardiothoracic Reg at tertiary centre. Advised to do a CTPA as may help determine whether RV mass is clot or tumour so whether he should be given heparin
• CTPA confirmed US findings: large pericardial effusion with 4.5-5cm diameter mass in RV. Also has a 13mm diameter pericardial nodule and multiple lung nodules and mediastinal lymphadenopathy suspicious for metastatic disease. Given absence of PE the RV mass is almost certainly tumour as well.
• Patient transferred to tertiary centre.
  
• I then met him in our hospital car park 6/52 later and he looked well and reported no pericardial drain or biopsy had been performed and he had immunotherapy and responded well so discharged after 2/52 inpatient admission

AUTHOR

​ALLAN WHITEHEAD
EMERGENCY PHYSICIAN BASS COAST HEALTH
CCPU (OTAGO) CCPU (ASUM)
snowydoogie@ozemail.com.au