 Welcome back to our MedSmarter question of the week where we're taking a smarter approach to preparing future physicians. Before we get started, if you'll take just a quick minute and click that like button and also subscribe and turn the bell on so that you'll be notified when we post new videos. Let's get right into this cardiology question. As always, we start with the last sentence of the vignette and then read the rest of the question so that we know what this is looking for. Which of the following complications is most likely causing the patient's symptoms? A 55-year-old man presents to the ED with chest pain. His preliminary workup showed that he was suffering a severe myocardial infarction. He is initially treated with nitrates, beta blockers, and aspirin and subsequently undergoes cardiac catheterization with placement of three stents. Following his procedure, he is hemodynamically stable without recurrence of chest pain. However, five days after admission, his resting heart rate is 129 beats per minute, blood pressure is 70 over 37, and respiratory rate is 30 breaths per minute. Physical exam reveals distant heart sounds and jugular venous distention. So which of the following complications is most likely causing the patient's symptoms? Before we get to the answer choices, let's look and see what the most important things to know here are. We're talking about a 55-year-old man had chest pain and was diagnosed with a myocardial infarction. They gave him the standard treatment for myocardial infarctions as well as cardiac catheterization with three stents. So we revascularized the coronary arteries. A main thing to note here is that this is referring to a certain time period. That time period is five days after admission. He has these symptoms occur where he is tachycardic, hypotensive, tachypnic, and has distant heart sounds and jugular venous distention. So we need to come up with an answer that matches these symptoms that happens five days after a myocardial infarction. So let's look at our answer choices. A, aneurysm formation. B, rupture of the papillary muscle. C, rupture of the ventricular free wall. D, fibrinous pericarditis. Or E, cardiac arrhythmia. Take a minute, read through the question and answer choices again. Come up with your answer and put it in the comment box below. Alright, so one of the things that we're looking at here is distant heart sounds. So we hear distant heart sounds often when we've got something blocking the transmission of sound from what we're listening to to our stethoscope. So what's something around the heart that can block the transmission of sound? We know that air actually makes things hyper-resonant and fluid makes it hypo-resonant. So we're talking about some sort of a fluid probably decreasing the sounds that we're able to hear. So based off that information, I know that I can already eliminate A, D and E because those don't have anything to do with fluid in the heart, okay? Now we're left with rupture of the papillary muscle and rupture of the ventricular free wall. Well, I do know rupture of the papillary muscle can occur within this time frame of about five days after myocardial infarction. This is going to be more of a mitral regurgitation and we would have different symptoms than this patient has. So that means I'm going to rule that out and rupture of ventricular free wall is going to be the answer choice that I choose. C. And C is the correct answer. So what we are dealing with is a complication associated with a myocardial infarction after the myocardial infarction occurs. There is a chart that I would highly recommend, you know, and that is going to tell us what particular events and complications can occur at what particular time frame after a myocardial infarction. With rupture of the ventricular free wall, we're typically going to see that blood is escaping the heart and causing a cardiac tamponade. So that's what you're seeing here where we have the distant heart sounds and jugular venous distention due to this free wall rupture and a cardiac tamponade being formed. So we're going to see hypotension, distant heart sounds, jugular venous distention, all on top of our tachycardia and tachypnea. A key thing for you to note is a patient's survival all depends upon the rapid recognition of this condition and the ability to immediately initiate therapy. We have to do a pericardiocentesis to go and immediately remove that fluid from around the heart to allow the heart to continue functioning properly. However, oftentimes these are likely fatal but it is something you need to be aware of and be vigilant to look for in patients. This chart right here is a great chart to know and understand as I mentioned a few minutes ago. What you're seeing here is the different complications associated with myocardial infarctions and their time frames. So within 24 hours the most common complications that we see are ventricular arrhythmias, heart failure, and cardiogenic shock. Within one to three days we're talking about post infarction fibrinous pericarditis, which would be D answer choice, but that's only within that one to three day range. Within three to 14 days, so a half a week up to about two weeks, we're talking about free wall rupture, papillary muscle rupture, or IV septum rupture. All of those things could rupture and you would see some different symptoms associated with each one. So that is where you may have to, on the exam, differentiate between a free wall rupture and a papillary muscle rupture, just like this question requires you to do. And then finally, two weeks onto months after myocardial infarction, we could see Dressler's syndrome, heart failure, arrhythmias, and ventricular aneurysms, which would give us a risk of murals thrombus to occur. If you found this material helpful for your studying, please like and consider subscribing to the channel. Also, share this video so that more people can benefit from it like you have.