Snapshot A 60-year-old woman presents with chest pain. She reports the chest pain started today and describes it as sharp and brief. When she sits up, the pain improves. She has no significant past medical history but endorses a viral respiratory infection a few days ago. On physical exam, she is in no acute distress. She has a low-grade fever. An electrocardiogram shows widespread ST segment elevation and PR depression in the precordial leads. 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 1-3 days after and several weeks after (Dressler syndrome) uremia rheumatic fever hemorrhagic tuberculosis malignancy constrictive radiation therapy open heart surgery 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 hypotension, tachycardia, and impaired diastolic filling in constrictive pericarditis Physical exam may have a fever friction rub pathognomonic Kussmaul sign seen in constrictive pericarditis ↑ jugular venous distention on inspiration Imaging Transthoracic 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, especially in lead II and in all leads except aVR 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 Nonoperative observation and treatment of the underlying cause indications in cases of asymptomatic or small pericardial effusion medical treatment NSAIDS for viral pericarditis steroids and immunosuppressants for SLE avoid immediately following MI to protect from ventricular wall rupture dialysis for uremia aspirin for post-MI pericarditis pericardiocentesis indications required for large effusions and cardiac tamponade Operative pericardiectomy reserved for recurrent disease Complications Pericardial effusion and tamponade
QUESTIONS 1 of 9 1 2 3 4 5 6 7 8 9 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 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK You have 100% on this question. Just skip this one for now. Take This Question Anyway (M3.CV.16.30) A 68-year-old male is admitted to your care four days after coronary artery bypass grafting (CABG) for a myocardial infarction (MI). The patient has a history of insulin-controlled diabetes, hypertension, and hyperlipidemia. Of note, the patient states that after the surgery, he had resolution of his chest pain, but he has started experiencing chest pain again. The patient states that the pain is exacerbated by deep breaths but feels better when he leans forward compared to lying down flat. On exam, his vitals are normal, and there are no murmurs heard on auscultation. His CK-mB returns as normal, and his repeat electrocardiogram (ECG) is shown in Figure A. What is the most likely diagnosis for this patient? Review Topic | Tested Concept QID: 102971 FIGURES: A Type & Select Correct Answer 1 Ventricular aneurysm 0% (0/3) 2 Ventricular septal rupture 0% (0/3) 3 Papillary muscle rupture 0% (0/3) 4 Acute pericarditis 67% (2/3) 5 Dressler's syndrome 33% (1/3) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 You have 100% on this question. Just skip this one for now. Take This Question Anyway (M2.CV.15.37) A 29-year-old woman is admitted with a two-day history of chest pain. The pain is sharp, worsens with inspiration or coughing, and improves when leaning forward. On further review, she endorses a polyarticular arthritis and has had two first-trimester spontaneous abortions. Her vitals are as follows: T 100.9 F, HR 101, BP 115/70, RR 14, SpO2 96% on room air. On exam, you auscultate a superficial squeaking sound along the anterior chest, best heard with the diaphragm of the stethoscope. You order an ECG and chest radiograph, which are pictured in Figure A and Figure B respectively. Which of the following laboratory tests would assist in your diagnosis? Review Topic | Tested Concept QID: 104043 FIGURES: A B Type & Select Correct Answer 1 Complete blood count (CBC) 9% (2/23) 2 Rheumatoid factor (RF) 4% (1/23) 3 Antinuclear antibody (ANA) 83% (19/23) 4 Parathyroid hormone (PTH) 0% (0/23) 5 Antineutrophil cytoplasmic antibody (ANCA) 0% (0/23) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 You have 100% on this question. Just skip this one for now. Take This Question Anyway (M3.CV.15.32) A 59-year-old woman presents to the emergency department with severe chest pain and shortness of breath. She reports that she was walking in her house when the pain began and it worsened when she laid down to go to bed later in the evening. She experiences relief of the chest pain when she sits down and leans forward with her chest over her knees. She was discharged from the hospital earlier today after suffering from an ST-elevation myocardial infarction 2 days ago that was successfully treated with coronary revascularization. Her past medical history is significant for hypertension and rheumatoid arthritis. Her temperature is 97.9°F (36.6°C), blood pressure is 155/105 mm Hg, pulse is 90/min, respirations are 13/min, and oxygen saturation is 98% on room air. Physical examination is significant for a friction rub on cardiac auscultation and an estimated jugular venous pressure of 11 cm H2O. An electrocardiogram is obtained and shown in Figure A. An echocardiogram is obtained and reveals good contractile function of the heart with an ejection fraction of 60% as well as the finding shown in Figure B. A chest radiograph reveals a cardiac silhouette within normal limits. Which of the following is the best management of this patient's condition? Review Topic | Tested Concept QID: 102973 FIGURES: A B Type & Select Correct Answer 1 Aspirin 0% (0/1) 2 Pericardial window 100% (1/1) 3 Pericardiectomy 0% (0/1) 4 Pericardiocentesis 0% (0/1) 5 Prednisone 0% (0/1) L 3 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 You have 100% on this question. Just skip this one for now. Take This Question Anyway (M2.CV.15.4043) A 65-year-old man presents to the emergency room with sharp chest pain and shortness of breath. He notes that he has been recovering from a gastrointestinal virus for the past several days, but that the chest pain was not present on previous days. During the physical exam, he notes that the pain seems to be decreased when he is seated and leaning forward. His systolic blood pressure is 150 mmHg on expiration and 141 mmHg on inspiration. An EKG is shown in Figure A. Assuming that the cause of this patient's cardiac condition is related to his recent viral illness, which of the following is the most appropriate treatment? Review Topic | Tested Concept QID: 107016 FIGURES: A Type & Select Correct Answer 1 Ibuprofen 75% (15/20) 2 Aspirin 5% (1/20) 3 Intravenous solumedrol 5% (1/20) 4 Dialysis 0% (0/20) 5 Urgent pericardiocentesis 10% (2/20) L 3 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1