Cindy Wagoner iHuman Chest Pain

Chief Complaint

Chest pain

History of Present illness (HPI)

Cindy is a 57-year old female presenting for evaluation of chest pain. The pain begun around 21/2 hours ago after a basketball game halftime. It started as a nagging pain but became increasingly severe. The pain radiates to the back when she takes a deeper breath but is localized deep in her chest. She describes it as sharp, stabbing, and constant. She has never experienced similar pain. It is constant and progressively worsening. The pain is mildly relieved with leaning forward and worsens with lying down, activity, or breathing with a severity of 8/10. She also reports a chronic smoker’s cough having being a smoker for 38 pack years. 10 days ago, she had a MI.

Physical Exam

Blood pressure
Pulse
Respiration
Temperature
SPO2
Test capillary refill
Inspect eyes
Inspect mouth/pharynx
Measure JVP (jugular venous pressure)
Visual inspection – anterior & posterior chest
Palpate anterior & posterior chest
Percuss anterior & posterior chest
Auscultate lungs
Palpate for PMI (point of maximal impact)
Auscultate heart
Visual inspection abdomen
Auscultate abdomen
Palpate abdomen
Visual inspection extremities
Palpate extremities

Case Problem Statement

A 57-year old female 10 days post inferolateral STEMI with stent placement, presents to the ED with a 2 hour history of progressively worsening chest pain. The pain is sharp/stabbing, worse with deep inspiration and movement, and sometimes “shooting” into her back with respiration, it is relived somewhat by sitting up and leaning forward. She reports mild nausea, without vomiting, denies fever/chills, palpitations, lightheadedness/syncope, shortness of breath, cough, intercurrent URI, or extremity/catheterization-site pain or swelling. She reports compliance with her antiplatelet medications (ASA and clopidogrel) since discharge. On exam, she is febrile (101.3) and has a pericardial friction rub. She is not hypotensive or hypoxic. PMH is significant for hypertension, hyperlipidemia. Tobacco abuse (38 pack/year history) and obesity.

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Index of Exercises

What are history and physical exam hallmarks in acute pericarditis?
1. Sharp or stabbing chest pain radiating to the ridge of the left trapezius (due to inflammation of the adjoining diaphragmatic pleura)
2. Pain may be worsened with deep inspiration or movement and is most severe when lying supine; better with sitting up and leaning forward
3. Respiratory phase and position have no bearing on the patient’s experience of chest; rather, the pain is dull and constant.
4. May have low grade fever, dyspnea, and dysphagia
5. Transient friction rub at the lower left sternal border or apex is the most common physical exam finding.

What triad of physical-exam findings is classic for pericardial tamponade?
1. Hypertension
2. Hypotension
3. Jugular Venous Distension
4. Unequal bilateral pulses
5. Muffled heart sounds
6. Blowing holosystolic murmur
7. Opening S1 click
8. Crescendo/decrescendo murmur

Management Plan

Diagnostic tests

Blood culture

Medications

Admit to cardiac unit for close cardiac monitoring
IV 0.9% Normal Saline (NS) 125mL/hr
Colchicine 0.5mg PO BID for 3 months (Chiabrando et al., 2020).
Ceftriaxone 2g IV 24 hourly for empiric treatment awaiting culture results (Chiabrando et al., 2020).
Continue current medications

Consults

Cardiology consult for further evaluation and management
Nutrition consult for dietary assessment and management

Client Education

Acute pericarditis refers to inflammation of the pericardium (the thin sac that surrounds the heart) that clinically presents with a sharp pleuritic chest pain which worsens with lying flat or inspiration and improves with either leaning forward or sitting up (Chiabrando et al., 2020).
Acute pericarditis can be as a result of infectious post-cardiac or inflammatory causes such as SLE, tuberculosis, toxoplasmosis, viral, or Dressler’s syndrome (Chiabrando et al., 2020). Your risk of acute pericarditis was as a result of the recent MI which presents a high risk of reoccurrence.
Your predisposing factors to acute pericarditis include; hyperlipidemia, hypertension (HTN), and recent MI.
Encourage medication adherence for prevention
Continue with smoking cessation to improve your overall recovery and health outcomes
Educate patient about the need for exercise & lifting restrictions.

Follow up

Follow up with cardiology in 1 week post discharge
Follow up with endocrinology for DM resistance.
Seek immediate care if you develop recurrent chest pain, shortness of breath (SOB) or fevers.

Reference

Chiabrando, J. G., Bonaventura, A., Vecchié, A., Wohlford, G. F., Mauro, A. G., Jordan, J. H., & Abbate, A. (2020). Management of acute and recurrent pericarditis: JACC state-of-the-art review. Journal of the American College of Cardiology, 75(1), 76-92.

Index of exercises

What features of acute pericarditis are associated with higher risk for complication and thus warrant hospital admission?

Fever(>38 degrees/100.4 degrees F) and leukocytosis
Hemodynamic evidence suggesting cardiac tamponade
A large pericardial effusion (i.e. an echo-free space of more than 20mm)
Immunosuppressed state
A history of therapy with vitamin K antagonists (e.g. warfarin)
Acute trauma
Failure to respond within seven days to NSAID therapy
Elevated cardiac troponin, which suggests my pericarditis

Which medication combination is recommended for treatment of pericarditis following a myocardial infarction?

Tylenol plus corticosteroids
Corticosteroids plus colchicine
NSAIDs plus colchicine
Aspirin plus colchicine
All of the above
None of the above

Which of the following medications when combined with NSAIDs has been shown to decrease the risk of recurrence of pericarditis?

Corticosteroids
Colchicine
Tylenol
All of the above
None of the above

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