A late diagnosis of bacterial pericarditis

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Background: Cardiac tamponade in patients with bacterial pericarditis has a high mortality rate. A timely diagnosis is crucial and can only be achieved through repeated systematic clinical evaluation, the use of POCUS and awareness of cognitive biases in clinical reasoning. Case description: A 56-year-old male was admitted to the emergency room with shortness of breath and chest pain. The patient became haemodynamically unstable and was treated for a septic shock. A POCUS showed signs of a cardiac tamponade, but these were not acknowledged as such. The diagnosis was delayed until the patient had a circulatory arrest. He was successfully resuscitated, and a pericardiocentesis showed a haemophilus influenzae pericarditis. The patient recovered well after pericardiocentesis and treatment with antibiotics. Discussion: For unstable patients, it is essential to conduct systematic assessments at regular intervals and whenever there is a change in clinical status. Cardiac and lung POCUS have proved to be useful in undifferentiated shock patients. Importantly, pericardial effusion should always be ruled out. For every clinician, it is important to be aware of possible cognitive biases in clinical reasoning and to use strategies to mitigate these risks. LEARNING POINTS: The central venous pressure should be assessed in all shock patients before and after fluid resuscitation.POCUS should be performed on all patients in shock to evaluate central venous filling and rule out pericardial effusion.If any significant pericardial fluid is found, tamponade should be considered as a contributing cause of hypoperfusion.Pericardial fluid removal rapidly improves haemodynamic status; the patient will not recover unless this is done.Awareness of cognitive biases in clinical reasoning, and strategies to mitigate them, are essential because such biases can contribute to medical errors.

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