Case 60: Chest Pain. Foundations Curriculum Oral Board Review Cases. v Chief complaint o 42- year- old male presents with chest pain

Transcription

1 Fundatins Curriculum Oral Bard Review Cases Case 60: Chest Pain v Chief cmplaint 42- year- ld male presents with chest pain v Vital signs HR: 101 BP: 136/82 RR: 14 T: 37.9 C Sat: 100% Wt: 80 kg v What des the patient lk like? Patient appears alert, sitting up n stretcher, in n acute distress. v Primary survey Airway: speaking full sentences Breathing: n respiratry distress, clear lungs Circulatin: warm and dry skin, 2+ distal pulses v Actin Place patient n the mnitr Tw large bre peripheral IV lines (draw rainbw tp) POC glucse (84, if requested) Stat EKG v Histry Surce: Patient, arrives by private vehicle HPI: a 42- year- ld male presents with chest pain fr the past 4 hurs. He describes the pain as slw in nset, gradually wrsening thrughut the day. The pain is lcalized t the mid chest, and is sharp, nn- radiating, wrse with inspiratin. There is assciated mild shrtness f breath. If asked, he reprts it is made wrse with lying dwn, and made better by sitting frward. If asked abut recent illnesses, he states that he had a cld abut a week ag that reslved n its wn. He tk a 5- hur flight within the U.S. 1 week ag. ROS is therwise negative. PMHx: nne PSHx: lives with wife and yung child, scial drinking, n smking r drugs Allergies: nne Meds: nne FHx: sister with +DVT during pregnancy, therwise negative PMD: Dr. Perry

2 v Secndary survey General: alert, sitting frward n stretcher, n acute distress HEENT: nrmal Chest: nntender Lungs: nrmal Heart: nrmal (frictin rub heard ver the left apex nly if learner perfrms serial exams) Abdmen: nrmal Extremities: nrmal Back: nrmal Neur: nrmal Skin: nrmal v Instructr Prmpt: discuss differential diagnsis (prmpt learners t risk stratify fr PE) v Nurse EKG (Figure sinus tachycardia, diffuse ST elevatins with PR depressins except in avr) v Actin Order labs CBC, BMP, LFT, trpnin, D- dimer Cnsider cagulatin studies, ESR, CRP, bld cultures x2 Order Imaging CXR POCUS: Ech t assess fr pericardial effusin Figure (A) parasternal lng and (B) parasternal shrt: small pericardial effusin, nrmal EF, n wall mtin abnrmality, n evidence f cardiac tampnade v Nurse Case 60 Lab Results (nrmal) Other Results: trpnin 0.03, D- dimer negative CXR (Figure nrmal chest x- ray) v Actin PO analgesia (NSAIDs) v Nurse Patient reprts that pain well cntrlled after NSAIDs Vitals after analgesia: HR: 81 BP: 120/80 v Actin Discuss diagnsis and treatment plan with patient Discharge patient hme with fllw- up instructins and return precautins

3 v Diagnsis Acute Pericarditis v Critical actins Stat EKG Thrugh histry and exam POCUS Ech t assess fr assciated pericardial effusin Analgesia with NSAIDs Ensure utpatient fllw- up with strict return precautins v Instructr Guide This is a case f pericarditis with classic presenting symptms and a classic EKG. It will be imprtant fr the learner t gather an apprpriately details histry and exam t evaluate fr alternate and life- threatening causes f chest pain. The patient is lw risk by Wells Scre but des nt meet the PE Rule- ut Criteria, s a D- dimer shuld be used t rule ut a PE. A trpnin (and bld cultures which can be drawn and held) shuld be sent t evaluate the ptential fr mycarditis and help determine need fr admissin. Imprtant actins include btaining a stat EKG, giving NSAIDs fr pain and cmpleting a POCUS ech t evaluate fr an assciated pericardial effusin. As this patient is therwise stable, has symptmatic imprvement with NSAIDS, and he has nly a small pericardial effusin, discharge hme with clse PCP fllw- up and strict return precautins is apprpriate. v Case Teaching Pints Pericarditis Inflammatin r infectin f the pericardial sac Majrity f cases are idipathic (up t 80%) r viral (1-10%) Other causes include bacterial, TB, pst- MI, malignancy, radiatin, uremia, rheum/cnnective tissue disease, and medicatins Symptms include sharp chest pain, classically psitinal and wrse with laying flat, +/- fever, +/- frictin rub; may reprt a preceding viral illness A pericardial frictin rub is usually a high- pitched, scratchy r squeaky sund heard best at the left sternal brder Classic frictin rub cnsists f 3 phases that crrespnd t the mvement f the heart during 3 phases f the cardiac cycle: atrial systle, ventricular systle, and rapid ventricular filling during early diastle EKG findings fr acute pericarditis include: Diffuse cncave ST- segment elevatins in all leads except fr avr +/- V1 which will shw ST- segment depressins STE are nt in a lcalized anatmical distributin Absence f any reciprcal changes except fr avr +/- V1 PR depressins in all leads with STE and PR elevatins in leads with STD (avr +/- V1) PR depressins are specific but nt sensitive fr pericarditis

4 A detailed histry and exam, in additin t screening labs will help t exclude ther causes f chest pain Bedside r frmal ech is imprtant t rule ut a significant pericardial effusin r pericardial tampnade Patients with uncmplicated idipathic r viral pericarditis can usually be managed as utpatients with 1-3 weeks f NSAID (ibuprfen r high dse aspirin > indmethacin) therapy unless there is evidence f mycarditis r significant pericardial fluid In sme patients, clchicine r sterids may be cnsidered as adjunctive therapy Mycarditis Inflammatin r infectin f the mycardium Called mypericarditis when there is cncmitant pericarditis Causes are similar t pericarditis Chagas Disease is the mst cmmn cause wrldwide Clinical presentatin is highly variable Can present with symptms similar t pericarditis May als reprt palpitatins, syncpe, r shw persistent tachycardia EKG may be similar t pericarditis but mst cmmnly shws nn- specific ST- T wave changes, may shw dysrhythmias, blcks, lw vltage QRS Findings that suggest mycarditis/mypericarditis (and nt just pericarditis): Reduced LV functin and EF n ech Significantly elevated trpnin Cmplicatins include CHF and arrhythmias Treatment shuld be supprtive, avid early NSAIDs r sterids Mst patients require admissin fr mnitring and treatment f underlying cause v POCUS Pearls POCUS t assess fr pericardial effusin and tampnade is a fundamental skill fr EM. Echcardigraphy: gld standard fr diagnsing pericardial effusin and shuld be perfrmed if the patient s cnditin allws it. Findings cnsistent with tampnade include the fllwing: Anechic stripe f fluid c/w pericardial effusin Diastlic cllapse f right ventricle and right atrium, when severe all chambers can cllapse Paradxical septal mtin Dilated/plethric IVC (a nrmal IVC essentially rules ut tampnade physilgy) Pericardial fluid appears as an anechic stripe psterir t the heart but anterir t the arta n parasternal lng view. Fluid accumulates psterirly, then anterirly. Subxiphid view is mst sensitive fr pericardial effusin Dn t be fled by the anterir fat pad, which is ften mistaken fr a pericardial effusin. If there is n psterir pericardial fluid, it is likely just the fat pad.

5 v References Original Case Surce: Emergency Medicine Oral Bard Review Illustrated (1st Editin), Dr. Yasuharu Okuda, Dr. Bret Nelsn, Case 60 (Authr: Dr. Braden Hexm) Primary Editr: Dr. Kristen Grabw Mre Additinal Editrs: Dr. Jennifer Rbertsn, Dr. Jeremy Berberian Ultrasund cntent by: Dr. Rachel Haney, Dr. Sierra Beck References: Original Case References: Tintinalli: Chapter 55, Rsen s: Chapter 81 Ma & Mateer s Emergency Ultrasund (3 rd Ed): Chapter 6 Nrthwestern Emergency Medicine POCUS Image Bank Medscape emedicine Pericarditis (Dr. Sean Spangler)

6 Case 60 Lab Results Cmplete bld cunt: WBC 10.1 x 10 3 /ul Hb 14.1 g/dl Hct 43.5% Plt 290 x 10 3 /ul Basic metablic panel: Na K Cl CO 2 BUN Cr Gluc Cagulatin panel: 135 meq/l 4.5 meq/l 101 meq/l 24 meq/l 15 mg/dl 0.9 mg/dl 80 mg/dl PT 13.1 sec PTT 26 sec INR 1.0 Liver functin panel: AST 32 U/L ALT 14 U/L Alk Phs 90 U/L T bili 1.1 mg/dl D bili 0.3 mg/dl Amylase 30 U/L Lipase 40 U/L Albumin 4.5 g/dl Urinalysis SG ph 6.8 Prt Neg Gluc Neg Ketnes Neg Bili Neg Bld Neg LE Neg Nitrite Neg Clr Yellw

7 Figure EKG

8 Figure CXR

9 Figure 60.3 A&B- POCUS Ech A. Parasternal Lng B. Parasternal Shrt