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Thread: A 23-year-old Caucasian male comes to the ER with complaints of left-sided chest pain.

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    Arrow A 23-year-old Caucasian male comes to the ER with complaints of left-sided chest pain.

    Clinical Case:

    Chief Complaint:

    A 23-year-old Caucasian male comes to the ER with complaints of left-sided chest pain. He reports the chest pain as constant and nonradiating.

    Physical Exam:

    He can't seem to get comfortable and has been taking aspirin over the last several days without relief. ECG shows mild elevation of the ST segment in leads I, II, III, aVF, and V1V6.
    What is the next step in management of this disorder?

    A. Oral or parenteral steroids.
    B. Change to ibuprofen 800 mg PO tid.
    C. Morphine.
    D. Morphine, oxygen, nitroglycerin, and aspirin.
    E. tPA therapy.


    Answer with Explanation:


    [HIDE]
    Answer: A. Oral or parenteral steroids.

    This young patient is likely suffering from acute pericarditis. Appropriate therapy was initially started by the patient and includes aspirin. However, since he has not improved and ECG changes are seen, a course of steroids, either orally or parenterally is indicated.
    [/HIDE]
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    For Your Reference:

    Pericarditis

    Pericarditis is a swelling and irritation of the pericardium, the thin sac-like membrane that surrounds your heart. Pericarditis often causes chest pain and sometimes other symptoms. Pericarditis may be acute or chronic. The sharp chest pain associated with acute pericarditis occurs when the pericardium rubs against the heart's outer layer.

    Mild cases may improve on their own. Treatment for more-severe cases may include medications and, rarely, surgery. Early diagnosis and treatment may help to reduce the risk of long-term complications.

    Symptoms

    If you have acute pericarditis, the most common symptom is sharp, stabbing chest pain behind the breastbone or in the left side of your chest. However, some people with acute pericarditis describe their chest pain as dull, achy or pressure-like instead, and of varying intensity. The sharp pain may travel into your left shoulder and neck. It often intensifies when you lie down or inhale deeply. Sitting up and leaning forward can often ease the pain. At times, it may be difficult to distinguish pericardial pain from the pain that occurs with a heart attack.

    Other signs and symptoms often associated with pericarditis include:

    •Shortness of breath when reclining
    •Low-grade fever
    •An overall sense of weakness, fatigue or feeling sick
    •Dry cough
    •Abdominal or leg swelling
    Causes

    Under normal circumstances, the two-layered pericardial sac that surrounds your heart contains a small amount of lubricating fluid. In pericarditis the sac becomes inflamed and the resulting friction from the inflamed sac rubbing against the outer layer of your heart leads to chest pain.

    In some cases the amount of fluid contained in the pericardial sac may increase, causing what is called pericardial effusion.

    The cause of pericarditis is often hard to determine. In most cases doctors are either unable to determine a cause (idiopathic) or suspect a viral infection.

    Pericarditis can also develop shortly after a major heart attack due to the irritation of the underlying damaged heart muscle. In addition, a delayed form of pericarditis may occur weeks after a heart attack or heart surgery because of antibody formation. This delayed pericarditis is known as Dressler's syndrome. Many experts believe Dressler's syndrome is due to an autoimmune response, a mistaken inflammatory response by the body to its own tissues — in this case, the heart and pericardium.

    Other causes of pericarditis include:

    Systemic inflammatory disorders. These may include lupus and rheumatoid arthritis.

    Trauma. Injury to your heart or chest may occur as a result of a motor vehicle or other accident.

    Other health disorders. These may include kidney failure, AIDS, tuberculosis and cancer.

    Certain medications. Some medications can cause pericarditis, although this unusual.


    Many of the symptoms of pericarditis are similar to those of other heart and lung conditions. The sooner you are evaluated, the sooner you can receive proper diagnosis and treatment. For example, although the cause of acute chest pain may be pericarditis, the cause could also be a heart attack or a blood clot of the lungs (pulmonary embolus).

    Tests and diagnosis

    Your doctor will likely begin by taking your medical history and asking questions about your chest pain and other symptoms.

    •Medical history and physical examination. Your doctor may ask whether you've recently experienced an upper respiratory infection or a flu-like sickness, and whether the chest pain worsens when you lie down or when you take a breath.

    •Physical exam. You may also undergo a physical examination and a review of whether you have or have had medical conditions, such as kidney disease, a recent heart attack or chest trauma.

    •Heart sounds. Your doctor may place a stethoscope on your chest to listen for the sounds characteristic of pericarditis, which are made when the pericardium rubs against the outer layer of your heart. Some doctors describe this characteristic noise as pericardial rub.

    Your doctor may have you undergo tests that can help determine whether you've had a heart attack, whether fluid has collected in the pericardial sac, or whether there are signs of inflammation. Your doctor may use blood tests to determine if a bacterial or other type of infection is present. You may also undergo one or more of the following diagnostic procedures:

    •Electrocardiogram (ECG). In this test, patches with wires (electrodes) are attached to your skin to measure the electrical impulses given off by your heart. Impulses are recorded as waves displayed on a monitor or printed on paper. Certain ECG results may indicate pericarditis.

    •Chest X-ray. With an X-ray of your chest, your doctor can study the size and shape of your heart. Images of your heart may show an enlarged heart if excess fluid has accumulated in the pericardium.

    •Echocardiogram. This test uses high-frequency sound waves to create a picture of your heart and its structures, including fluid accumulation in the pericardium. Your doctor can view and analyze this image on a monitor.

    •Computerized tomography (CT). This X-ray technique can produce more-detailed images of your heart and the pericardium than would conventional X-ray studies. CT scanning may also be performed to exclude other causes of acute chest pain, such as blood clots in your lung arteries (pulmonary emboli) or a tear in your aorta (aortic dissection).

    •Magnetic resonance imaging (MRI). This technique uses a magnetic field and radio waves to create cross-sectional images of your heart that can reveal thickening or other changes in the pericardium.

    Complications

    Complications may include:

    •Constrictive pericarditis. Some people with pericarditis, particularly those with long-term inflammation and chronic recurrences, can develop permanent thickening, scarring and contracture of the pericardium. In these people, the pericardium loses much of its elasticity and resembles a rigid case that's tight around the heart, which keeps the heart from working properly. This condition is called constrictive pericarditis and often leads to severe swelling of the legs and abdomen, as well as shortness of breath.

    •Cardiac tamponade. When too much fluid collects in the pericardium, a condition called cardiac tamponade can develop. Excess fluid puts pressure on the heart and doesn't allow it to fill properly. That means less blood leaves the heart, which causes a dramatic drop in blood pressure. If left untreated, cardiac tamponade can be fatal.
    Early diagnosis and treatment of pericarditis usually reduces the risk of the long-term complications.

    Treatments and drugs

    Deciding upon treatment for pericarditis will likely involve consideration of the underlying cause as well as the severity. Mild cases of pericarditis may get better on their own without treatment.

    Rest and medications

    Your doctor may recommend bed rest until you're feeling better. Medications to reduce the inflammation and swelling associated with pericarditis are often prescribed. Most pain associated with pericarditis responds well to treatment with aspirin or another nonsteroidal anti-inflammatory drug (NSAID). If your pain is severe, you might need stronger pain medications, such as a narcotic, for a short time.

    Acute episodes of pericarditis typically last from one to three weeks, but future episodes can occur. About one in five people with pericarditis has a recurrence within months of the original episode. People who have repeated episodes of pericarditis are often treated with a drug called colchicine, and sometimes steroid medications are used.

    When a bacterial infection is the underlying cause of pericarditis, you'll be treated with antibiotics and drainage if necessary.

    Hospitalization and procedures

    You'll likely need hospitalization if your doctor suspects cardiac tamponade, a potentially dangerous complication of pericarditis. When cardiac tamponade is present, you may undergo a technique called pericardiocentesis. In some cases of severe pericarditis, your doctor might suggest surgically removing your pericardium (pericardiectomy).

    •Pericardiocentesis. In this procedure, a doctor uses a sterile needle or a small tube (catheter) to remove and drain the excess fluid from the pericardial cavity. You'll receive a local anesthetic before undergoing pericardiocentesis, which is often done with echocardiogram monitoring and ultrasound guidance. This drainage may continue for several days during the course of your hospitalization.

    •Pericardiectomy. If you're diagnosed with constrictive pericarditis, you may need to undergo a surgical procedure (pericardiectomy) to remove the entire pericardium that has become rigid and is compromising the functioning of your heart.

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