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Emergency NP (ENP)

Emergency Nurse Practitioner Certification Exam


The Anatomy of a Question


A 37-year-old man who received a liver transplant three years ago presents with a two-week history of progressively worsening dyspnea and dull chest pain that is somewhat alleviated by sitting upright and bending slightly forward. His ECG demonstrates global low voltage as well as an electrical alternans pattern. What are the expected findings on this patient’s physical exam?

Answer choice options
  • A. Abdominal distention
  • B. Auscultated crackles
  • C. Chest wall tenderness on palpation
  • D. Muffled S1 and S2

The incorrect options (distractors) are not totally wrong. These options can be diagramed as follows:

Most Correct
Least Correct
  • D.
    Muffled S1 and S2 Classically associated with tamponade due to fluid in the pericardial sac.
  • B.
    Auscultated crackles More closely associated with pneumonia on lung exam.
  • A.
    Abdominal distention May be seen in fluid overload state, but less common than muffled heart sounds.
  • C.
    Chest wall tenderness on palpation Seen with costochondritis.

The Anatomy of an Explanation

This patient is presenting with signs, symptoms, and diagnostic findings concerning for subacute pericardial tamponade. The finding of low voltage is attributed to the attenuation of electrical signal traveling through the increased amount of pericardial fluid. Given the causative pericardial effusion, a clinician would expect to hear muffled heart sounds. Most subacute pericardial tamponade patients report a bothersome dyspnea that is caused by the resulting pump failure and a dull chest pain that is attributed to the underlying pericarditis. The ECG finding of electrical alternans is due to the heart “swinging” within the restrictive pericardial fluid, thus, changing the electrical axis reported to the ECG machine. Tamponade is a medical emergency and should be treated with a pericardiocentesis.

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Emergency Nurse Practitioner (ENP)

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