HPIA 35 yo female presents to the ED with chest pain that started this morning.
Gordon, Greg, Coordinating Producer has reference to this Academic Journal, PHwiki organized this Journal HPIA 35 yo female presents to the ED with chest pain that started this morning. She had cold-like symptoms earlier in the week. She has an important presentation at work this afternoon about her recent meeting with investors in Japan in addition to wants to know how long it is going to take to find out what is wrong.What else would you like to askHPIOnsetSettingSeverityQualityLocation, RadiationDurationFrequencyAggravating FactorsAlleviating FactorsAssociated SymptomsHPIOnset – Sudden, acuteSetting – Started when she woke up this morningSeverity – 10/10!Quality – SharpLocation, Radiation – Left-sided, radiating to left shoulderDuration – 2 hoursFrequency – No previous episodesAggravating Factors – Inspiration, lying down, coughing, swallowingAlleviating Factors – Sitting up in addition to leaning as long as wardAssociated Symptoms – palpitationsWhat else do you want to know
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PMHMedical Hx: C-section (2009)Family Hx: non-contributory, no family history of heart disease or bleeding disordersSocial: Married with 2 children, works in finance, one glass of wine per week, denies tobacco in addition to illicit drug useWhat is your differential diagnosisDDxAcute MIPulmonary EmbolismPneumothoraxPneumoniaPericarditisAsthmaGERDAnxietyWhat do you want to do nextPhysical ExamVitals: BP 120/80, T 99.0, HR 80, RR 20General: Patient is sitting on the edge of the hospital bed leaning as long as wardHEENT, Abdominal, Neuro, in addition to Psych Exams: wnlCV: RRR, no murmurs, rub heard at left lower sternal border at the end of expirationRespiratory: shallow breaths, able to speak in full sentences, lungs clear to auscultation bilaterallyWhat labs do you want to order in addition to why
Lab TestsCardiac Markers rule out MICBC evaluate as long as infection, inflammationElectrolytes increased risk of arrhythmias in pericarditisCRP, ESR evaluate as long as inflammationD-dimer rule out PE (low suspicion)CXR evaluate as long as pneumonia, pneumothorax, PE, effusionECG rule out MI, pericarditisLab ResultsTroponin I – < 10 g/LCBC, electrolytes normal CRP 16 mg/LESR 25 mm/hD-Dimer 100 ng/mL ECGWhats your impression of the ECG Widespread ST elevation without reciprocal depressionPR depression in lead IIChest X-RayNote the cardiomegalyHow can we further evaluate this enlarged heartCardiac Echo shows pericardial effusionRV right ventricleLV left ventricleLA left atriumAo aortaPE pericardial effusion Chest CTThick arrow pericardial effusionThin arrow pleural effusionOverview of Acute PericarditisInflammation of the pericardial sac accompanied by pericardial effusion Bread in addition to Butter HeartHistology of Acute PericarditisPMNs adhering to the epicardium Overview of Acute PericarditisMany possible causes, including:Idiopathic (usu. post-viral)Infection (viral, bacterial, fungal)Acute MIDresslers syndromeSLEDrug-induced (procainamide, hydralazine)AmyloidosisRadiationPost-surgeryHallmarks of Acute PericarditisSymptoms: Chest painPleuritic, associated with breathingPositional relieved by sitting up in addition to leaning as long as wardDyspneaPalpitations+/- fever, non-productive coughHallmarks of Acute PericarditisECG Changes diffuse ST-segment elevation in addition to PR depressionPhysical Exam Findings:Friction rubPulsus paradoxusDistant Heart Sounds Pericardial Friction RubPathognomonic as long as acute pericarditisHeard best at left lower sternal edge with patient sitting up, leaning as long as ward, & exhalingHigh-pitched, grating sound with 3 componentshttp://www.youtube.com/watchv=J1R8OxgqhfkPulsus Paradoxus> 10 mmHg fall in systolic blood pressure during inspirationSeen with cardiac tamponade, asthma, pericarditisTreatmentNSAIDs, medium to high doses 1st lineCorticosteroids if NSAIDs fail or are contraindicated, recurrent pericarditisColchicine prevents recurrent pericarditisPericardiocentesis as long as large effusion with hemodynamic compromise, cardiac tamponade, or diagnostic purposesPericardiectomy as long as persistent constrictive pericarditis
PearlsAcute Pericarditis Key Findings (need 2 of 4 as long as diagnosis):Pleuritic chest pain improved by leaning as long as wardPericardial friction rubWidespread ST elevation on ECGPericardial effusionSummaryThe patient was diagnosed with acute pericarditis in addition to started on NSAID therapyShe continued to be in stable condition in addition to was discharged from the ED with instructions to follow-up with her PCPShe was told to expect her symptoms to resolve in 2 weeks to 3 months
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