Jackie Johnson Acute Pericarditis discussion

Jackie Johnson is described as a married 35-year-old African American female who has presented to the emergency room with: Chest pain, which she rates 8 out of 10 on a scale ranging from 1 to 10. The pain is verbalized to be sharp in nature, worsens with deep breaths, is retrosternal, and is improved when “leaning forward”. In addition, she also indicates having had “flu like illness” within the past few days such as fever, rhinorrhea, and cough. She denies any additional medical history and is not taking any medication. Also, she denies any alcohol, tobacco, or drug use. Of note, she is reported to work as an Advertising Executive.

Upon physical examination findings she appears in moderate distress from pain, with a blood pressure of 125/85 mm Hg, heart rate 105 bpm, respiratory rate 18/min, and oxygen saturation of 98% on room air. She is currently afebrile. Her head and neck examination are notable for clear mucus in the nasal passages and a mildly erythematous oropharynx. The neck is supple, with shotty anterior cervical lymphadenopathy. The chest is clear to auscultation. Jugular veins are not distended. Cardiac examination is tachycardic with a three-component high-pitched squeaking sound. Abdominal and extremity examinations are normal.

Given the patients report and the physical examination obtained, factors aside from medical findings to keep in mind when moving forward are: A highly stressful job, her sex, her race, and her marital status, which may contribute to stress levels as well.

After assessment of the findings presented, J.J’s likely Diagnosis is Acute Pericarditis, which is an inflammation of the pericardium, caused by the sac’s layers becoming inflamed and possibly rubbing against the heart (American Heart Association, 2016). A client with acute pericarditis will complain of chest pain that worsens with deep breaths or while coughing when lying down and is relieved by positional changes, such as leaning forward or sitting up (Hammer & McPhee, 2014). Also, a clinical finding in patients with acute pericarditis is a high-pitched squeaking sound upon cardiac auscultation, which may be indicative of pericardial rub (Hammer & McPhee, 2014). The presence of pericardial rub often indicates complications of pericarditis such as an increase in fluid between the layers of the pericardium which causes the rubbing between the pericardium and heart, pericardial effusion (Hammer & McPhee, 2014), this best explains the pathophysiological mechanism causing the chest pain for J.J currently.  J.J’s cardiac exam shows tachycardia, as evidenced by a heart rate of 105, with a three-component high pitched squeaking sound, which is a finding indicative of acute pericarditis, but may also be indicative of complications related to pericarditis (American Heart Association, 2016).

Causes of pericarditis include viral, bacterial, protozoal, and mycotic infections (Hammer & McPhee, 2014) or its cause can be idiopathic. Per J.J’s report of  “flu like illness for the past few days” which include fever, rhinorrhea, and cough lead me to believe that a likely cause of the pericarditis is a virus. The mild erythematous oropharynx, and shotty anterior cervical lymphadenopathy noted during the physical exam are also indicative of viral cause.

Though acute pericarditis is the likely diagnosis for J.J given her relatively healthy history, further assessment and diagnostic testing should be obtained to confirm and or rule out other cardiac related illnesses that may present with similar symptoms. In the case of J.J, the symptoms presented do not coincide with clinical manifestations exhibited in other cardiac related illnesses. Her blood pressure is within normal limits, her respirations are normal, O2 Sat is WNL, jugular veins are not distended, and is not experiencing dyspnea. The clinical findings exhibited: elevated heart rate, mild erythematous oropharynx, shotty anterior cervical lymphadenopathy, tachycardia with 3-component high pitched squeaking sound are all symptoms that point to pericarditis. However, we must also take into consideration that there are non-cardiac related conditions that can also present in the form of chest pain (Fass, R., & Achem, S.R, 2011).  Psychological disorders such as panic, anxiety, and depression can also clinically manifest with chest pain (Huffman, J., Pollack, M., & Stern, T., 2002). Given J.J’s high demanding job, we can suspect that she experiences high levels of stress that can contribute to anxiety, but in order to further diagnose this, more information needs to be obtained.

Considering that, “Heart disease and stroke are the No. 1 killers in women, and affects African American women disproportionately, making diabetes, smoking, high blood pressure, high cholesterol, physical inactivity, obesity and a family history of heart disease all greatly prevalent among African-Americans and are major risk factors for heart disease” (American Heart Association, 2016), I would want to investigate further into family history, and monitoring of cholesterol as well as potential for hypertension.

In order to increase J.J’s prognosis, a thorough assessment should be completed including an ECG, Chest X-ray, echocardiogram, and obtaining labs for signs of inflammation (American Heart Association, 2016). In addition, perhaps also including cholesterol screening would be helpful collateral information to better treat J.J. Currently, her blood pressure appears to be within normal limits, but I would want to monitor this as well. Lastly, I’d also want to examine J.J’s psychological and mental status to rule out anxiety related disorders, which could have also contributed to her chest pain.

Acute Pericarditis has been known to clear up on its own with simple treatment (American Heart Association, 2016).  Treatment, however, will be dependent on the cause (American Heart Association, 2016). Upon discharge, the recommendation for J.J will likely be anti-inflammatory medication in higher doses than usual, such as Motrin, or Aleve in order to alleviate the pain, and rest (American Heart Association, 2016), since she has no other known medical history and is relatively young. She should follow up with a cardiologist to monitor for recurrence.

 

References:

American Heart Association (2016, March 31). Retrieved from

https://www.heart.org/en/health-topics/pericarditis/what-is-pericarditis

Fass, R., Achem, S.R. (2011).  Noncardiac Chest Pain: Epidemiology, Natural Course and            Pathogenesis.  Journal of Neurogastroenterology and Motility,17:110-

123.https://doi.org/10.5056/jnm.2011.17.2.110

Hammer, G., & McPhee, S. (2014). Pathophysiology of disease: An introduction to clinical                    medicine  (8th ed.). New York, NY: McGraw-Hill Medical.

Huffman, J., Pollack, M., & Stern, T. (2002). Panic Disorder and Chest Pain: Mechanisms,

Morbidity, and Management. Primary Care Companion to The Journal of Clinical

            Psychiatry, 4(2):54-62.doi: 10.4088/pcc.v04n0203

Discussion 2

Jackie Johnson, a 35 y.o. African-American, married female, advertising executive, presents to the emergency department with complaints of chest pain. The pain is described as 8 on a scale ranging from 1 to 10, retrosternal, and sharp in nature. It radiates to the back, is worse with taking a deep breath, and is improved by leaning forward. On review of systems, she has noted a “flulike illness” over the last several days, including fever, rhinorrhea, and cough. She has no medical history and is taking no medications. She denies tobacco, alcohol, or drug use. On physical examination, she appears in moderate distress from pain, with a blood pressure of 125/85 mm Hg, heart rate 105 bpm, respiratory rate 18/min, and oxygen saturation of 98% on room air. She is currently afebrile. Her head and neck examination is notable for clear mucus in the nasal passages and a mildly erythematous oropharynx. The neck is supple, with shotty anterior cervical lymphadenopathy. The chest is clear to auscultation. Jugular veins are not distended. Cardiac examination is tachycardic with a three-component high-pitched squeaking sound. Abdominal and extremity examinations are normal.

In this discussion:

  1. Provide and discuss this patient’s likely diagnosis with your colleagues. Why do you support this “likely” diagnosis?
  2. Discuss your differential diagnoses clinical reasoning. Why do you support this list of potential differential diagnoses?
  3. Provide and discuss what the most common causes of this disease are, and which is most likely in this patient?
  4. Identify the pathophysiologic mechanism for her chest pain.
  5. Develop a plan of care post-discharge based upon your recommendations living arrangements and social supports.

Support your discussion with citations from the external literature and your textbook.

Remember to respond to at least two of your peers. Please refer to the Course Syllabus for Participation Guidelines & Grading Criteria.

Discussion 2 – Pleuritic Chest Pain

Case: Jackie Johnson, a 35 y.o. African-American, married female, advertising executive, presents to the emergency department with complaints of chest pain. The pain is described as 8 on a scale ranging from 1 to 10, retrosternal, and sharp in nature. It radiates to the back, is worse with taking a deep breath, and is improved by leaning forward. On review of systems, she has noted a “flu-like illness” over the last several days, including fever, rhinorrhea, and cough. She has no medical history and is taking no medications. She denies tobacco, alcohol, or drug use. On physical examination, she appears in moderate distress from pain, with a blood pressure of 125/85 mm Hg, heart rate 105 bpm, respiratory rate 18/min, and oxygen saturation of 98% on room air. She is currently afebrile. Her head and neck examination are notable for clear mucus in the nasal passages and a mildly erythematous oropharynx. The neck is supple, with shotty anterior cervical lymphadenopathy. The chest is clear to auscultation. Jugular veins are not distended. Cardiac examination is tachycardic with a three-component high-pitched squeaking sound. Abdominal and extremity examinations are normal.

  1. Provide and discuss this patient’s likely diagnosis with your colleagues. Why do you support this “likely” diagnosis?

Upon initial presentation, a clue that the chest pain may be pleuritic in nature is related to the symptoms the patient describes as sharp pain that increases while taking a deep breath, and the pain is located retrosternal with movement of the chest pain to the back. These are classic symptoms of pleuritic chest pain (Hammer & McPhee, 2019; Reamy, Williams, & Odom, 2017). Upon further examination with a repositioning test, the patient voices improvement of chest pain when leaning forward which validates that somatic nerves of the parietal pleura are sensitized with inflammation that is commonly seen in pleuritic chest pain. Further assessment of a “pericardial rub” (an audible high-pitched or squeaking noise as sticky inflammatory fluid in the pericardial sac moves between the visceral and parietal pericardial layers) lends another layer of confirmation, that the patient’s chest pain is pleuritic and possibly due to pericarditis because a pericardial rub is also found to be a classic sign used in developing a diagnosis of pericarditis (Gupta, 2019; Hammer & McPhee, 2019).

  1. Discuss your differential diagnoses clinical reasoning. Why do you support this list of potential differential diagnoses?

Pleuritic chest pain can be caused by other conditions. The most serious and life-threatening conditions such as pulmonary embolism, myocardial infarction, aortic dissection, pneumonia, and pneumothorax, have similar signs and symptoms, and diagnostic clinically reasoning can help the practitioner discern, contrast and compare between them quickly to anticipate and plan for life saving interventions. For example, approximately 5% to 21% of emergency department patients are found to have a pleuritic chest discomfort with a pulmonary embolism. In fact, 66% of patients experienced pleuritic chest pain which was associated with a pulmonary embolism (Reamy, Williams, & Odom, 2017, 306). On the other hand, sharp chest pain is usually not cardiac. Also, if you have a pretty good clue of the diagnosis, such as in this case, pericarditis, then you would want to consider the possible related complications such as pericardial effusion, constrictive pericarditis and cardiac tamponade. However, over 80% of pericarditis cases have good outcomes, so searching for other causes may not always be warranted (Imazio, 2020)

It is important to look at other causes, associated signs and symptoms, and complete tests that can help you validate a definitive diagnosis. For instance, an EKG may show occasional ST elevation in pericarditis, whereas, in contrast, adjacent leads will show consistent ST elevation along with elevated cardiac enzymes in myocardial infarction. And a chest x-ray is often normal with myocardial infarction, but may show cardiomegaly in pericarditis (Reamy, Williams, & Odom, 2017, p. 310).

The working diagnoses, I would probably consider, after a through physical exam and history is pericarditis. Differential diagnoses of a new or old myocardial infarction,  pulmonary embolism, or pneumonia could possibly be considered. Diagnostic evidence such as a chest x-ray will help to identify the size of the heart, the condition of the pericardium, and the condition of the lungs which will aid in discerning a probable diagnosis.

  1. Provide and discuss what the most common causes of this disease are, and which is most likely in this patient?

The most common causes of  pericarditis is inflammation caused by infections from virus (primarily the coxsackievirus), bacteria, protozoal, and mycotic; collagen-vascular related diseases, such as systemic lupus erythematosus, rheumatoid arthritis; neoplasm; metabolic, such as renal failure; injury such as myocardial infarction, post myocardial infarction, and trauma; idiopathic in which the disease presents itself without a defining reason (Hammer & McPhee, 2019, p. 320). Since the patient has had recent flu symptoms and anterior cervical lymphadenopathy with symptoms classic for pericarditis, her condition is mostly likely caused by a viral infection.

  1. Identify the pathophysiologic mechanism for her chest pain.

Pericarditis is caused by inflammation of the pericardial sac. The inflammation builds up sticky fluid that grinds against the pericardial surfaces of the visceral and parietal surfaces. The inflammation will initiate growth of polymorphonuclear leukocytes, cause pus type accumulation, and buildup of fibrin material (Hammer & McPhee, 2019). There are no pain receptors in the visceral pleura; however, in response to inflammation, the parietal pleura’s pain receptors are stimulated, and the parietal pleurae and lateral hemidiaphragm can sensitize cutaneous nerves towards the surface of the skin. Swelling and inflammation to these innervated areas can cause increased pain such as with respiratory movement (Reamy, Williams, & Odom, 2017).

  1. Develop a plan of care post-discharge based upon your recommendations living arrangements and social supports.

Ms. Johnson is a young and currently working a successful job. It would be good to explore with Ms. Johnson her support system at home, and consider involving a significant other in the education related to her diagnosis and treatment plan. With an unremarkable work-up, discussing with Ms. Johnson home self-care options would probably be safe if she is agreeable to following the home care guidelines, and follow-up for re-evaluation as scheduled. Home therapy would possibly include activity restrictions to include no strenuous exercise, treatment regimen with NSAIDs and colchicine for one to two weeks. Follow-up with the patient via a phone conference in one week, and then a follow-up office visit in two weeks would be a good way to monitor if she is responding to the therapy (Imazio, 2020).

References:

Gupta, J. (2019, June). Cardiac Auscultation. Retrieved from https://www.merckmanuals.com/professional/cardiovascular-disorders/approach-to-the-cardiac-patient/cardiac-auscultation

Hammer, G. D., & McPhee, S. (2019). Pathophysiology of Disease: An Introduction to Clinical Medicine (8 ed.). New Youk: McGraw-Hill Education Medical.

Imazio, M. (2020, February 21). Acute pericarditis: Treatment and prognosis. Retrieved https://www.uptodate.com/contents/acute-pericarditis-treatment-and-prognosis

Reamy, B. V., Williams, P. M., & Odom, M. R. (2017, September 1). Pleuritic chest pain: Sorting through the differential diagnosis. American Family Physician, 306-312. Retrieved from https://www.aafp.org/afp/2017/0901/p306.html

 

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