Editor's Note: This is the first half of a two-part Patient Case Quiz. Go to Part II.

Case A Presentation: A 58-year-old female with no past medical history presents to your clinic for a second opinion regarding her chronic pericardial effusion. The effusion was discovered incidentally eight years ago on an echocardiogram performed prior to elective knee surgery. At baseline, she feels quite well and is able to walk 3-5 miles daily and participates in moderate intensity exercise. Her local physician has been following the effusion with yearly echocardiograms and sends reports demonstrating that the size of the effusion has not drastically changed over the years. She received a trial of a non-steroidal anti-inflammatory agent and colchicine 0.6 mg daily for six months, but this failed to change the size of the effusion.

In addition she has been experiencing palpitations on a daily basis for the past six months with increasing frequency and was ultimately diagnosed with paroxysmal atrial tachycardia. Each episode can last up to 20 minutes in duration. Given the symptomatic nature of the arrhythmia, she was recently started on metoprolol 25 mg daily. She denies fevers, arthralgias, chest pain, dyspnea, or swelling.

Physical exam: Pleasant middle-aged female in no acute distress. Blood pressure 134/65, pulse 52, respirations 12, body mass index 23 kg/meters-squared. Her JVP is 7 cm and lungs are clear without any gallop or murmur. Her skin is warm and she has no lower extremity swelling. Abdominal exam shows no organomegaly.

Laboratory testing: Thyroid stimulating hormone normal; Sedimentation rate 9 mm/hr; C-reactive protein 0.5 mg/L; CK-MB negative, Troponin negative. ANA and Rheumatoid Factor were negative. Sodium 143, Potassium 4.1, Chloride 104, Bicarbonate 26, Blood urea nitrogen 18, Creatinine 0.80. She had normal liver enzymes and a normal complete blood count.

EKG: Sinus rhythm, 60 bpm, sinus arrhythmia is present. QRS duration 96 milliseconds. PR interval is 200 milliseconds. Corrected QT interval is 440 milliseconds.

Echocardiogram: Normal left ventricular size, normal systolic and diastolic function. Right ventricle is normal in size with normal systolic function. Estimated RV pressure is 26 mmHg. Left and right atrial cavities are normal in size. There is no major valvular regurgitation or stenosis. There is a large circumferential pericardial effusion measuring 22 mm posteriorly. There is no right atrial or right ventricular diastolic inversion.

Cardiac MRI: No pericardial delayed enhancement.

Video 1: Subcostal

Video 2: Long Axis