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case_images: (A) ECG showing sinus bradycardia and low voltage limb leads. (B) Chest X-ray showing water bottle configuration.
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case_images: At the Emergency Department, 12L ECG showed sinus bradycardia, low voltage limb leads and non-specific ST-T wave changes (Figure 2A). Chest radiograph showed an enlarged heart with water bottle configuration (Figure 2B).
case_images: 2D echocardiogram with Doppler studies done on admission showed an echo free space posterior to the left ventricle, anterior to the right ventricle and superior to the right atrium with widest diameter of 4.0 cm suggestive of large pericardial effusion. There was an exaggerated respiratory variation of 19.6% at peak mitral inflow and 37.8% at peak tricuspid inflow suggestive of Doppler evidence of tamponade.
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case_images: A 2-dimensional echocardiogram confirmed the presence of massive PEEF with doppler evidence of tamponade (Figure 3).
case_images: Follow up plain 2D echocardiogram done 4 days later showed a decrease in amount of pericardial effusion with widest diameter now measuring 2.1 cm from previous 4.0 cm, with noted RA collapse during systole and RV collapse during diastole suggestive of echocardiographic evidence of tamponade.
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case_images: Repeat 2D echocardiography after several days of medical management showed a decrease in the pericardial effusion (Figure 4) and patient was subsequently discharged.
case_images: 2D echocardiogram with Doppler studies done 16 days after the first study showed a further decrease in amount of pericardial effusion with widest diameter now measuring 1.49 cm from previous 2.1 cm, consistent with moderate pericardial effusion, with echocardiographic evidence of tamponade.
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case_images: Outpatient followup showed further resolution of effusion (Figure 5).