Mehl. pericarditis + NBME 10 111 pericarditis Flashcards
NBME 10 111.
57-year-old woman comes to the emergency department because of a 1-day history of constant sharp chest pain and shortness of breath. The pain is located to the left of her sternum, increases when she lies on her back, and decreases when she sits and leans forward. Temp. 37.6°C, pulse is 62/min, RR 24/min, BP 87/55 mm Hg, SpO2 88 proc. JVP is 9; Ley 15k. An ECG shows diffuse ST-segment elevation. A CT scan of the chest with contrast is shown (sustorejes perikardas). BEST NEXT STEP IN DX?
Echocardiography
NBME 10 111.
Her other examination findings, including slightly increased jugular venous pressure and hypotension with hypoxia suggest that she may also have heart failure or a hemodynamically significant pericardial effusion.
The CT scan demonstrates a small to moderate circumferential pericardial effusion, which is frequently seen in patients with pericarditis, but given this patient’s hypoxia and hypotension, this should be urgently evaluated with echocardiography to ensure that she does not require a pericardiocentesis to treat pericardial tamponade.
Echocardiography will also be able to evaluate left ventricular systolic function.
NBME 10 111. pericarditis Tx?
High-dose aspirin or nonsteroidal anti-inflammatory drugs in combination with colchicine. Causes of pericarditis include viral infection, malignancy, autoimmune disease, and tuberculosis, although the majority are eventually deemed idiopathic.
NBME 10 111. pericarditis.
Patients with hypotension and hypoxia, which are concerning for a hemodynamically significant pericardial effusion, should be evaluated urgently with echocardiography.
.
Mehl. ECG?
ECG as diffuse ST-elevations (i.e., in all leads rather than 3-4 contiguous leads as with MI). PR depressions can also be seen, but I’ve never seen the USMLE give a fuck about the latter.
Mehl. Pain when worsens?
Patient will have pain that’s worse when lying back
Mehl. Pain when relieves?
Leaning forward.
In turn, the patient can present walking through the door bent over at the waist.
Mehl. Serous pericarditis will be post-viral, secondary to autoimmune disease, or due to cocaine use.
.
Mehl. NBME Q gives pericarditis + a bunch of different organism types. Answer?
“virus.”
Mehl.
Patient with rheumatoid arthritis or SLE notably at risk for pericarditis. In other words, don’t get confused if they mention pericardial friction rub in vignette of RA or SLE; this is common.
atsimenu step1 buvo RA + pericarditis. ir cause buvo viral blet
Mehl. For cocaine use, they’ll say a 22-year-old male has chest pain after a night of heavy partying + ECG shows diffuse ST-elevations, Dx?
pericarditis.
Mehl. Uremic pericarditis is HY for 2CK. Q will give ultra-high creatinine and BUN and say there’s a friction rub -> treatment = ?
hemodialysis.
Mehl. pericarditis Tx?
Treatment for pericarditis is same as acute gout.
NSAIDs, colchicine - bet cia for acute.
paskui tik steroids.
Mehl. Fibrinous pericarditis is post-MI and occurs as two types. 1?
1) literally “post-MI fibrinous pericarditis,” which will simply be friction rub within days of an MI;
Mehl. Fibrinous pericarditis is post-MI and occurs as two types. 2?
2) Dressler syndrome (antibody-mediated fibrinous pericarditis occurring 2-6 weeks post-MI).
Mehl. pericarditis - first step in Dx?
ECG
but USMLE wants echocardiography as next best step in order to visualize a concomitant effusion that can occur sometimes.
Mehl. Vignette will give you stereotypical pericarditis + will ask for next best step in diagnosis; ECG might not be listed and you’re like huh? Answer is echocardiography to look for potential effusion concomitant to the pericarditis.
.
Mehl. Chronic constrictive pericarditis.
I should make note that chronic constrictive pericarditis is a separate condition that doesn’t present with the standard pericarditis findings as described above.
This is low-yield for USMLE, but students ask about it because it can be confused with tamponade.
.
Mehl. Chronic constrictive pericarditis.
There’s two ways this can show up.
Mehl. Chronic constrictive pericarditis.
There’s two ways this can show up. 1 - classic cause?
1) Tuberculosis is a classic cause; there may or may not be calcification around the heart on imaging. So if you get a Q where patient has TB + some sort of heart-filling impairment, answer = chronic constrictive pericarditis.
Mehl. Chronic constrictive pericarditis.
There’s two ways this can show up. 2 - what sign present?
2) Kussmaul sign will be seen in the Q, where JVD occurs with inspiration rather than expiration.
Mehl. Chronic constrictive pericarditis.
Normally, inspiration facilitates RA filling (decr. intrathoracic pressure –> incr. pulmonary vascular compliance/stretching. -> incr. high-low pressure gradient from right heart to the lungs -> decr. in afterload on RV from the lungs -> blood moves easier from right heart to the lungs -> blood is pulled easier from SVC/IVC to the RA).
.
Mehl. Chronic constrictive pericarditis.
However, if there is incr. compressive force on the heart, the incr. in negative intrathoracic pressure during inspiration is not transmitted to the right side of the heart, so JVP does not decr. (and can even paradoxically can incr.).
Mehl. Chronic constrictive pericarditis.
In tamponade, however, as discussed below, the incr. in negative intrathoracic pressure during inspiration is able to be transmitted to the right side of the heart, so Kussmaul sign does not occur. This is likely because in constrictive pericarditis, the rigid pericardium prevents expansion of the right heart altogether, whereas in tamponade, the pericardium isn’t rigid per se, but is just filled with blood that can move/shift during the respiratory cycle, thereby allowing right heart expansion during inspiration.
.
