Snapshot A 58-year-old woman with a past medical history of systemic lupus erythematosus presents to the emergency room for sharp chest pain. She reports that it is worse with inspiration and gets better when she leans forward. On physical exam, there is a friction rub that is loudest when she leans forward. An electrocardiogram shows widespread ST elevation. Introduction Clinical definition inflammation of the pericardium characterized by sharp pain worsened by inhalation Etiology serous autoimmune disease systemic lupus erythematosus rheumatoid arthritis uremia viral illness coxsackievirus fibrinous pericarditis complication of myocardial infarction (MI) 1-3 days after and several weeks after (Dressler syndrome) the MI systemic lupus erythematosus uremia rheumatic fever hemorrhagic tuberculosis malignancy constrictive radiation therapy viral illness tuberculosis Pathogenesis inflammation of the pericardium can cause chest pain movement of the heart can cause friction between the 2 pericardial layers, producing a friction rub inflammation may cause a pericardial effusion Prognosis can be acute or chronic, and may recur viral pericarditis is usually self-limited Presentation Symptoms sharp pleuritic chest pain that is worsened by inhalation pain is also relieved by sitting up and leaning forward shoulder pain (referred pain) pericarditis is innervated by phrenic nerve Physical exam may have a fever friction rub pathognomonic Kussmaul sign seen in constrictive pericarditis ↑ jugular venous distention on inspiration Imaging Echocardiography indication to assess for pericardial effusion and cardiac tamponade Radiography indication to rule out pneumonia or other pulmonary pathology findings constrictive pericarditis may have pericardial calcifications on radiography Studies Labs ↑ erythrocyte sedimentation rate ↑ C-reactive protein may have ↑ troponin I Electrocardiogram (ECG) PR segment depression and in all leads except aVR but especially in lead II leep <a target="_blank" href="https://www.medbullets.com/step1-stats/1030/sleep" rel="nofollow">www.medbullets.com/step1-stats/1030/sleep</a> widespread ST segment elevation upright T waves weeks after pericarditis, this will become inverted T waves classic ECG signs may be absent in uremic pericarditis Making the diagnosis based on clinical presentation and ECG findings Differential Cardiac tamponade distinguishing factor pulsus paradoxus and Beck triad on exam Myocardial infarction distinguishing factor more focal ST elevation on ECG suggestive of anatomic damage Treatment Conservative restriction of exercise indication for all patients Medical nonsteroidal anti-inflammatory drugs (NSAIDs) indication best initial therapy drugs indomethacin naproxen ibuprofen aspirin prednisone indication pain refractory to NSAIDs colchicine indication adjunct therapy to NSAIDs or steroids Non-operative pericardiocentesis indication in patients with pericardial effusion or cardiac tamponade dialysis indication for patients with pericarditis from uremia Complications Pericardial effusion and tamponade
QUESTIONS 1 of 6 1 2 3 4 5 6 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? Review Topic QID: 100546 1 Pain improves with inspiration 6% (5/78) 2 Pain relieved by sitting up and leaning forward 51% (40/78) 3 High-pitched diastolic murmur 18% (14/78) 4 Fixed and split S2 9% (7/78) 5 Mid-systolic click 15% (12/78) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 2 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? Review Topic QID: 100725 1 Pulmonary hypertension 0% (0/7) 2 Interstitial lung disease 0% (0/7) 3 Acute myocardial infarction 0% (0/7) 4 Pericarditis 100% (7/7) 5 Pericardial tamponade 0% (0/7) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (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? Review Topic QID: 100620 1 Increase in jugular venous pressure on inspiration 34% (33/96) 2 Exaggerated amplitude of pulse on inspiration 19% (18/96) 3 Pulsatile abdominal mass 5% (5/96) 4 Continuous machine-like murmur 10% (10/96) 5 S3 heart sound 22% (21/96) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (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? Review Topic QID: 100553 1 Cardiac tamponade 3% (1/31) 2 Constrictive pericarditis 16% (5/31) 3 Acute pericarditis 74% (23/31) 4 Libman-Sacks endocarditis 3% (1/31) 5 Acute myocardial infarction 3% (1/31) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 3
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