CCS Interactive Case 24

Question 1

47 y/o M, hx HTN, presents to ED, 1 day history of sharp, retrosternal chest pain worse with inspiration, relieved by leaning forward. Flu-like illness 1 week ago, febrile for 2 days. Fever of 101.6F, HDS.

DDx?

Answer 1

Acute pericarditis

MI, PE, pneumonia, GERD, MSK

Question 2

Next steps?

Answer 2

Emergency orders - pulse ox, oxygen, IV access, monitor, EKG

Question 3

O2 98%, EKG with diffuse ST segment elevation - exam?

Answer 3

Focused - general, cadiac, lung

Question 4

Pericardial friction rub, otherwise normal - underlying causes of acute pericarditis?

Answer 4

Viral agents, neoplasm, uremia, autoimmune disease, TB, bacteria, acute MI, trauma

Question 5

Studies?

Answer 5

CBC, BMP, CXR, echocardiography, blood cultures, ESR, cardiac enzymes

[Tuberculin skin testing, ANA, HIV if cause is unclear]

Question 6

CXR and echo reveal pericardial effusion, no evidence of tamponade. ESR elevated. CBC w/lymphocytosis. Cardiac enzymes reveal elevated CK, normal troponin. Labs otherwise normal. Dx?

Answer 6

Idiopathic pericarditis

Question 7

Next step?

Answer 7

Rx w/NSAIDs and colchicine for idiopathic or viral, continue NSAIDs while symptoms, colchicine for 3 months
Avoid NSAIDs other than aspirin in post-MI pericarditis
Steroids if idiopathic or viral percarditis resistant to NSAIDs and colchicine
Steroids if due to autoimmune disease
Rx underlying cause
Admit to hospital due to fever
Pericardiocentesis not indicate given absence of tamponade and acute nature of effusion

Question 8

Indications for admission?

Answer 8

Fever>100.4, cardiac tamponade, failure to respond to NSAIDs within 1 week, immunosuppressed, anticoagulated, acute trauma, elevated troponin

Question 9

Sequence

Answer 9

Order - pulse ox, oxygen, cardiac monitor, IV access, BP monitor, EKG 12 lead (Stat)
Exam - focused
Clock - advance to obtain EKG results - note diffuse ST elevations (pericarditis)
Order - CBC, BMP, CXR, cardiac enzymes, ESR, blood culture, ibuprofen, colchicine - all stat
Location - admit to ward
Order - ambulate at will, regular diet, echo (routine), reassurance, cancel O2
Clock - advance to obtain echo result - effusion but no tamponade
Order - cancel monitor cardiac and BP, IV access
Clock - reevaluate daily until symptoms improve, then cancel vitals, order counseling, send home
F/u in 2 weeks, case ends
Final orders - none
Dx - acute pericarditis