Transcript NP Rounds August 9, 2011

A Case of Two Chest Pains
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July 12th :57 y/o woman presenting to urgent care
with c/o chest pain and dysnea - face flushed,
anxious, appearing in distress with sudden c/o of
dizziness and SOB, no N/V/diaphoresis
Chest pain gradual worsening since last night –
central cp with dysnpea, thought it was heartburn –
had started tapering her dose of prednisone being
treated for pericarditis
VS: 112/47 HRR 106 RR 28 O2 sat 98% RA afebrile
Initial interventions: 100% O2 sat w/ 3/l ,ECG NSR,
troponin 0.00, IV access – toradol 30 mg
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Medications: Prednisone 25 mg – only one
tapered dose of 20 mg, last hs took 25 mg;
Nexium 40 mg od
Allergies: NKA
PMH: recent episode pericarditis – being
followed by CR Internal Medicine: Echo July
7th = borderline LVH, mild LV/RV septal wall
dyssychrony, EF 70%, L atrium borderline
dilated, mild mitral valve sclerosis &
calcification w/ small pericardial effusion, no
cardiac tamponade
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CT chest July 7th = decreased effusion,
thickening of pericardium query constrictive
pericardium
Social hx: recent loss of husband d/t massive
MI at home; has custody of her
granddaughter, and parent living with her
P/E: Resp,CVS unremarkable, no rub
Labs ordered this visit: Cr, K+, ESR, Random
Glucose
Consult with GP colleague: pericarditis
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Monitored for few hours to ensure pain and
dyspnea settled
Continue with 25 mg dose of prednisone
Had follow up appointment with Internal
Medicine in CR
Encouraged to follow up with regular office
appointment
RTC urgent if symptoms worsening
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Seen in urgent care again July 19th – more
dramatic presentation – acute onset of
central, anterior chest pain, continuous,
sharp, rates 10/10 radiating to back, should,
neck with abd cramping – walked in with
assistance, unsteady, flused, tachypneic
Current meds Prednisone 25 mg, Nexium 40
mg, Tramadol
O2, IV Toradol, ECG unchanged
Internal Medicine consult
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66 y/o man walked in to urgent care July 13th
with c/o chest pain x 2 days describes as
more discomfort central radiating to R
shoulder and scapula – hx of pericariditis
post CABG Dec 2010 pain prior has been on L
side only
Reports sharp pain with deep breath but no
SOB, nausea, vomiting, diaphoresis, anxiety
Recently ++fatigued, napping ++ during day
Waking at night with worsening shoulder pain
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Has taken 6 tablets of ibuprofen in last 24 hours
with little improvement
Wife concerned it is his heart, encouraged him to
be assessed
Medications: Omeprazole 20 mg od, Metoprolol 25
mg bid, ASA 81 mg od, Pravastatin 80 mg od,
Metformin 500 mg bid, Fenofibrate 145 mg od
Allergies: iodine
Previous labs normal eGFR 62 A1c 6%
PMH: GERD, Dyslipidemia, DM Type 2, Quad bypass
post MI Dec 2010, pericariditis Jan 2011, R rotator
cuff tear (inferior labral tear) June 2011
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P/E:
◦ Respiratory unremarkable
◦ CVS: S1 & S2 slurred no elevated JVP, VS: 117/77
HRR 81 RR 16 02 sat 99% RA afebrile
◦ MSK: limited ROM R shoulder d/t pain
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ECG: NSR query 1 degree AV block & septal
changes, Troponin 0.00, Na 144, K+ 3.3 Cl
110 Glucose 4.5 Creat 70 Urea 3.6 Hgb 122
IV access: Toradol 30 mg IV
Discharged with follow up with Internal
Medicine
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Angina Pectoris
Aortic Dissection
Aortic Stenosis
Coronary Artery Vasospasm
Esophageal Rupture
Esophageal Spasm
Esophagitis
Gastritis, Acute
Gastroesophageal Reflux Disease
Myocardial Infarction
Myocardial Ischemia
Peptic Ulcer Disease
Pulmonary Embolism
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Fatigue
Fever
Pain worse when lying down
Palpitations
Dyspnea
Clinical Pearls:
◦ Likely pericariditis if pain improved with NSAIDS
◦ Likely pericariditis if pain improved with sitting up
and leaning forward
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Common disease, frequently subclinical=
inflammation of the pericaridium (fibrous sac
surrounding the heart)
Recurrent pericarditis is most commonly
observed in the cases of acute nonspecific
pericarditis. The recurrence rate appears to be in
the range of 15% to 32% after an initial attack.
Causes:
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Idiopathic
Infectious: viral (CMV, HIV, Herpes), bacterial, fungal
Systemic disease
Dressler’s: post MI
Trauma
Neoplasm
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Pericarditis can be classified according to the
composition of the inflammatory exudate or in
other words the composition of the fluid that
accumulates around the heart.[1]
Types include:
serous
purulent
fibrinous
caseous
hemorrhagic
Post infarction
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Depending on the time of presentation and
duration, pericarditis is divided into "acute“ (more
common) and "chronic" forms.
Acute pericarditis can occur as a complication of
infections, immunologic conditions, or MI
Chronic or constrictive pericarditis is a less
common
Clinical classification of acute vs. chronic:
◦ Acute (<6 weeks)
◦ Subacute (6 weeks to 6 months)
◦ Chronic (>6 months
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Chest pain characteristic of pericarditis:
Substernal or left precordial pleuritic
Radiation to trapezius ridge
Relieved by sitting up/bending forward
Worsened by recumbent position or deep breath
May resemble angina/MI but differs in that pain changes with body
positions
◦ Other symptoms may be dry cough, fever, fatigue, anxiety
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Due to similarity to myocardial infarction pain, pericarditis
can be misdiagnosed as an acute MI solely based on the
clinical data therefore extreme suspicion on the part of the
diagnostician is required
Characteristic/Parameter
Pericarditis
Myocardial infarction
Pain description
Sharp, pleuritic, retro-sternal
(under the sternum) or left
precordial (left chest) pain
Crushing, pressure-like, heavy
pain. Described as "elephant on
the chest."
Radiation
Pain radiates to the trapezius
ridge (to the lowest portion of the Pain radiates to the jaw, or the
scapula on the back) or no
left or arm, or does not radiate.
radiation.
Exertion
Does not change the pain
Can increase the pain
Position
Pain is worse supine or upon
inspiration (breathing in)
Not positional
Sudden pain, that lasts for hours
or sometimes days before a
patient comes to the ER
Sudden or chronically worsening
pain that can come and go in
paroxysm or it can last for hours
before the patient decides to
come to the ER
Onset/duration
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The classic sign of pericarditis is a friction rub auscultated at
the left sternal border
Other signs include:
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positional chest pain
Diaphoresis
pulsus paradoxus
Beck’s triad:
 which describes three medical signs associated with acute cardiac
tamponade, a medical emergency due to fluid accumulation around the
heart impairing the heart’s ability to pump blood observed as:
 Low arterial blood pressure
 Jugular venous distension
 Distant and muffled heart sounds (narrowing of pulse pressure may also be
observed)
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ASA/NSAIDS for viral/idiopathic causes
Pericardiocentesis for effusion/cardiac tamponade
Antibiotics for bacterial infections
Steroids in acute pericariditis but may increase risk
for recurrence
constrictive pericarditis is a late sequela of an
inflammatory condition of the pericaridum. The
inflammatory condition is usually an infection that
involves the pericardium, but it may be after a MI
or after heart surgey
http://en.wikipedia.org/wiki/Pericarditis
http://www.medicinenet.com/pericarditis/article.htm
http://www.stjosham.on.ca/media/PatientED/PT/Pericarditis-trh.pdf
http://emedicine.medscape.com/article/156951-differential
http://www.drugs.com/cg/chronic-pericarditis.html