N512 Acute Pericarditis

N512 Acute Pericarditis

Mrs. Johnson is a thirty-five-year-old married Black female. Of importance, she presents with chest pain, rated as an eight on a scale of 1-10, that is sharp, located behind the sternum and radiates to the back. Pain increases on inhalation and is made better with leaning forward. Medical history non-contributory. Denies active medications and tobacco, alcohol, and drug use. N512 Acute Pericarditis Vitals reveal mild tachycardia. Patient confirms flu-like illness, but currently afebrile. Physical exam positive for mucus in nasal passage, erythematous oropharynx, and high-pitched squeaking sound.

Mrs. Johnson’s likely diagnosis is acute pericarditis. She presents with the classic indications of pericarditis pain (Hammer & McPhee, 2019):

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  • Sharp and retrosternal in nature
  • N512 Acute Pericarditis
  • Worsens with deep breathing, coughing, lying flat
  • Improved with sitting upright and leaning forward

A high pitched three component squeaking sound is also heard on cardiac examination. She could potentially have infection, acute myocardial infarction, thoracic cavity trauma. Although medication side effects can potentially cause some of these symptoms, she reports no medication use to include street drugs. N512 Acute Pericarditis According to Hammer and McPhee, “Viruses, particularly, the coxsackieviruses, are the most common cause of acute pericarditis. Viruses are also probably responsible for “idiopathic” pericarditis” (2019). Other potential viral culprits include echovirus, adenoviruses, parvovirus B19, HIV, influenza as well as multiple herpes viruses such as EBV and CMV. There is also evidence of bacterial infections as etiologies, but it is not usually seen in developed countries (Dababneh & Siddique, 2020) N512 Acute Pericarditis. Based on clinical presentation of shotty anterior cervical lymphadenopathy, the most likely etiology is viral infection. This is further strengthened by the patient’s report of recent flu-like illness. According to Dababneh & Siddique, “Due to the parietal layer’s rich innervation, any inflammatory process mediated by an infectious, autoimmune or traumatic insult can result in severe retrosternal chest pain, as is commonly seen in acute pericarditis. N512 Acute Pericarditis This explains why the vast majority of presentations (>90%) have chest discomfort” (2020). A thorough post discharge plan of care would include:

  • Educating patient on indicators of worsening disease processes. When to notify primary care provider, when to seek emergency help
  • Take prescribed medicines as directed. First line of treatment is most often NSAIDS. Some cases will also require treatment with antibiotics and/ or steroids.
  • Eat a healthy diet. Drink appropriate fluids. Get enough sleep/exercise. N512 Acute Pericarditis
  • Manage stress. According to the case study she is married. Utilize family support to decrease anxiety and tension. Assess job responsibilities as a potential source of stress and implement ways to lower strain.

References

Dababneh, E., & Siddique, M. S. (2020). Pericarditis. In StatPearls. StatPearls Publishing. N512 Acute Pericarditis

Hammer, G. & McPhee, S. (2019). Pathophysiology of disease: An introduction to clinical medicine (8th ed.). New York, NY: McGraw-Hill Education /Medical

 

Discussion 2

Jackie Johnson, a 35 y.o. African-American, married female, advertising executive, presents to the emergency department with complaints of chest pain N512 Acute Pericarditis. 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. N512 Acute Pericarditis 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 N512 Acute Pericarditis.
  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.

The symptoms experienced by 35-year-old Jackie Johnson is suggestive of acute pericarditis which I strongly support based upon her history.  Her presenting complaint is sharp retrosternal chest pain radiating to the back which worsens with deep breaths and improves when leaning forward, 8 out of 10 on the pain scale.  She further complains of “flu-like illness”, fever, rhinorrhea, and cough for several days and denies any previous medical or medication history.  Her cardiac examination revealed that she was tachycardic with a pulse rate of 105 and a three-component high-pitched squeaking sound.  Pericarditis is the inflammation of the pericardium which is a fluid-filled sac surrounding the heart and is commonly diagnosed in a primary care setting based on physical examination, and electrocardiogram (ECG), and patient history such as the symptoms experienced by Jackie Johnson (Rahman & Saraswat, 2017) N512 Acute Pericarditis.

Some differential diagnosis would include myocardial infarction (MI), pulmonary embolism, and pneumonia to name a few (Rahman & Saraswat, 2017).  Chest pains are quite common in an MI so cardiac enzymes and an ECG would be needed to rule this out.  Pulmonary embolism also can present with chest pains so a D-dimer blood test and lung scans can rule this out. N512 Acute Pericarditis The patient also complained of cough, fever, and  “flu-like” symptoms which can be caused by pneumonia so a chest x-ray, blood cultures, and a complete blood count can confirm this diagnosis.  “The characteristic ECG findings in patients with acute pericarditis are a diffuse elevation of the ST-segment and ST-segment depression in lead aVR and depression of the PR segment, especially in leads V5 and V6 (Saricam & Saglam, 2016).

There are multiple causes for pericarditis and the most common is a viral disease caused by the coxsackievirus but bacterial, mycotic organisms, and tuberculosis can be the causal factors in addition to other medical conditions such as neoplasms and autoimmune diseases such as rheumatoid arthritis (Hammer & McPhee, 2019).  Based on Jackie Johnson’s complaint of “flu-like” symptoms, she may have a viral cause for her pericarditis.  Her chest pain was probably caused by the inflammation of the pericardium and the three-component high-pitched squeaking sound in her heart was likely due to pericardial friction rub (Hammer & McPhee, 2019) N512 Acute Pericarditis.

Before discharge planning, I will have a conversation with the physician, patient, and spouse to be clear on the medication, follow-up appointment, psycho-social considerations, and activity restrictions.  With this information, I will teach the patient about the medications and side effects, notifying her physician if there is any worsening of symptoms, make sure she has a follow-up appointment, offer her psychological counseling if needed, advise her of social support groups, and stress the importance of rest and avoidance of strenuous activities (Rahman & Saraswat, 2017).

References

 

Hammer, G. & McPhee, S. (2019). Pathophysiology of disease: An introduction to clinical medicine (8th ed.). New York, NY: McGraw-Hill Education /Medical

Rahman, A., & Saraswat, A. (2017). Pericarditis. Australian Family Physician, 46(11), 810-814. Retrieved from https://search-proquest-  com.americansentinel.idm.oclc.org/docview/1961747048?pq-origsite=summon N512 Acute Pericarditis

Saricam, E., & Saglam, Y. (2016). Potentially missed acute pericarditis: Atypical pericarditis. The American Journal of Emergency Medicine, 34(12), 2451-2453. doi:http://dx.doi.org.americansentinel.idm.oclc.org/10.1016/j.ajem.2016.09.020  Retrieved from https://search-proquest-com.americansentinel.idm.oclc.org/docview/1961747048?pq-origsite=summon N512 Acute Pericarditis

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