questions 5

Pericarditis

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Topic updated on 12/22/16 12:35pm

Snap Shot
  • A 63-year-old male presents with severe chest pain that is alleviated when the patient leans forward. Physical exam reveals elevated JVP on inspiration and a friction rub best heard when the patient leans forward. ECG shows ST elevation in all leads and PR depression in the precordial leads.
Introduction
  • Definition
    • inflammation of the pericardial sac often with an effusion
  • Types
    • serous
      • caused by
        • SLE  
        • RA
        • viral infection 
        • uremia
    • fibrinous
      • caused by
        • commonly found with effusion
        • uremia
        • myocardial infarction
          • immediately after
          • several weeks after (Dressler's syndrome)
        • rheumatic fever
    • hemorrhagic
      • caused by
        • TB
        • cancer
    • constrictive
      • caused by
        • open heart surgery
        • radiotherapy to the mediastinum
        • TB
        • idiopathic
Anatomy
  • The normal pericardium consists of two layers
    • a fibrous outer layer
    • serous inner layer
Presentation
  • Patients present with
    • dyspnea
    • cough
    • fever often after URI
    • pleuritic chest pain
      • pain is positional in nature 
        • worse when patient is supine and alleviated when the patient leans forward 
      • pain is worse with deep inspiration
    • possible effusion
  • Physical Exam shows
    • pericardial friction rub  
      • best heard with patient leaning forward
    • may hear pericardial knock
      • sound of ventricle hitting thickened pericardium during diastole
    • Kussmaul's sign
      • increase in JVP on inspiration 
Evaluation
  • EKG shows 
    • low voltage and ST segment elevation in all leads 
  • Echocardiogram
    • shows thickened walls 
Treatment
  • Nonoperative
    • observation & treatment of underlying cause
      • indications
        • in cases of asymptomatic or small pericardial effusion
    • pericardiocentesis
      • indications
        • required for large effusions & cardiac tamponade
  • Operative
    • pericardiectomy
      • reserved for recurrent disease


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Qbank (4 Questions)

TAG
(M1.CV.30) A 35-year-old African-American female presents to the emergency room complaining of chest pain. She also complains of recent onset arthritis and increased photosensitivity. Physical examination reveals bilateral facial rash. Which of the following is most likely to be observed in this patient? Topic Review Topic

1. Pain improves with inspiration
2. Pain relieved by sitting up and leaning forward
3. High-pitched diastolic murmur
4. Displaced apical impulse
5. Mid-systolic click

PREFERRED RESPONSE ▶
TAG
(M1.CV.37) A 45-year-old African-American woman presents with dyspnea, cough, and non-radiating chest pain. Her chest pain is relieved by leaning forward and worsens upon leaning backwards. A scratchy rub is heard best with the patient leaning forward. Physical examination did not elucidate evidence of a positive Kussmaul's sign, pulsus paradoxus, or pericardial knock. The patient most likely is suffering from which of the following? Topic Review Topic

1. Cardiac tamponade
2. Constrictive pericarditis
3. Acute pericarditis
4. Libman-Sacks endocarditis
5. Acute myocardial infarction

PREFERRED RESPONSE ▶
TAG
(M1.CV.104) A 35-year-old Caucasian female with a history of rheumatoid arthritis presents to your clinic with pleuritic chest pain that improves while leaning forward. Which of the following additional findings would you expect to observe in this patient? Topic Review Topic

1. Increase in jugular venous pressure on inspiration
2. Exaggerated amplitude of pulse on inspiration
3. Pulsatile abdominal mass
4. Continuous machine-like murmur
5. S3 heart sound

PREFERRED RESPONSE ▶
TAG
(M1.CV.209) A 34-year-old Caucasian female presents at the ER with fever and sharp pain in her chest upon coughing and inhalation. Three weeks earlier she presented to her rheumatologist with a butterfly rash, joint pain and fatigue and was given a diagnosis of systemic lupus erythematosus. A friction rub is present upon physical exam. Which of the following do you most suspect in this patient? Topic Review Topic

1. Pulmonary hypertension
2. Interstitial lung disease
3. Acute myocardial infarction
4. Pericarditis
5. Pericardial tamponade

PREFERRED RESPONSE ▶
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