PERICARDITIS
What is the classic presentation of acute pericarditis?
Sharp, pleuritic chest pain that is worse when lying down and relieved by sitting forward, often accompanied by a pericardial friction rub.
What is the typical clinical presentation of acute myocarditis?
Chest pain, dyspnea, fatigue, palpitations, or symptoms of heart failure (orthopnea, edema) in a patient with recent viral illness, ranging from mild symptoms to cardiogenic shock.
What are the key characteristics of an innocent (functional) heart murmur?
Systolic only, soft (grade 1-2/6), musical or vibratory quality, no radiation, changes with position, asymptomatic child.
What are the red flags in a child with chest pain that warrant immediate action in urgent care?
Exertional chest pain, syncope with chest pain, family history of sudden cardiac death, abnormal cardiac exam, severe pain at rest, or associated dyspnea/diaphoresis.
What key elements must be documented when evaluating a pediatric murmur to support your clinical decision?
Timing (systolic/diastolic), grade (1-6/6), location, quality, radiation, positional changes, complete cardiovascular exam, symptoms, and rationale for disposition.
What are the diagnostic ECG findings in pericarditis and how do you differentiate them from STEMI?
Diffuse concave-upward (saddle-shaped) ST elevation with PR depression, versus localized convex ST elevation with reciprocal changes in STEMI.
Why doesn't troponin elevation in myocarditis carry the same prognostic significance as in ACS?
Troponin elevation in myocarditis reflects myocardial injury but does NOT correlate with mortality or long-term outcomes like it does in acute coronary syndrome.
What are the red flags that indicate a pathologic murmur requiring cardiology referral?
Diastolic murmurs, holosystolic murmurs, loud/harsh (>grade 3/6), radiation to back/neck, associated symptoms (cyanosis, poor feeding, failure to thrive, syncope).
What red flags in an infant's feeding history suggest underlying cardiac pathology?
Prolonged feeding times (>30 minutes), diaphoresis with feeds, tachypnea during feeds, poor weight gain, or needing frequent breaks during feeding.
What HPI elements are essential when documenting chest pain in a pediatric patient?
Onset, quality, location, duration, associated symptoms (syncope, palpitations, dyspnea), exertional relationship, alleviating/aggravating factors, and previous episodes.
What are the diagnostic criteria for acute pericarditis?
Diagnosis requires 2 of 4 criteria: typical chest pain, pericardial friction rub, ECG changes (widespread ST elevation or PR depression), and new or worsening pericardial effusion.
What ECG findings are seen in myocarditis and how do they overlap with pericarditis?
Nonspecific ST-T wave changes, PR depression, sinus tachycardia, ventricular arrhythmias, or conduction delays; unlike pericarditis, may show pathologic Q waves or regional changes if focal involvement.
What is the "stand-up test" and why is it useful in urgent care?
Have the child stand up from supine position - if the murmur disappears when standing, it is very likely innocent.
What are the red flags for coarctation of aorta that every urgent care provider must recognize?
Weak or absent femoral pulses, upper extremity BP >10 mmHg higher than lower extremity BP, differential pulses between arms and legs, or upper extremity hypertension.
What family history questions are crucial to document when evaluating a child with cardiac symptoms or murmur?
Sudden cardiac death before age 50, cardiomyopathy, congenital heart disease, arrhythmias/pacemakers, unexplained drownings/accidents, and genetic syndromes.
What is the first-line treatment for uncomplicated acute pericarditis in the urgent care setting?
NSAIDs (ibuprofen 600-800mg TID or aspirin 750-1000mg TID) plus colchicine 0.5-0.6mg daily or BID for 3 months, with activity restriction.
How do you differentiate myocarditis from pericarditis clinically?
Myocarditis shows ventricular dysfunction, regional wall motion abnormalities on echo, higher troponin levels, symptoms of heart failure, and arrhythmias; pericarditis typically preserves ventricular function.
What is a Still's murmur and what are its characteristics?
The most common innocent murmur; a grade 1-2/6 vibratory, musical systolic murmur heard best at left lower sternal border, louder supine, in children ages 3-6 years.
What red flags in a child's exercise history suggest serious cardiac pathology?
Syncope or near-syncope with exercise, chest pain that stops activity, palpitations during exercise, family history of sudden death, or child stopping activities they previously tolerated.
How should you document the HPI for a febrile child with suspected pericarditis or myocarditis?
Fever onset/duration, chest pain characteristics, recent viral illness, dyspnea, positional relief, functional status change, and cardiac symptom review including palpitations and syncope.
What are the red flags requiring immediate cardiology referral or hospital admission in pericarditis?
High fever (>38°C), large pericardial effusion, tamponade signs, failure to respond to NSAIDs within 7 days, immunosuppression, trauma, myocarditis, or anticoagulation use.
What is the appropriate disposition for a patient with suspected myocarditis in urgent care?
Immediate cardiology consultation and hospital admission for echocardiography, cardiac MRI consideration, telemetry monitoring, and exclusion of acute coronary syndrome.
What is a venous hum and how do you make it disappear?
A continuous, low-pitched murmur heard over the neck vessels that disappears when supine, with neck rotation, or with gentle jugular vein compression.
What are the red flags for myocarditis in a child presenting with "viral illness" symptoms?
Chest pain, significant tachycardia out of proportion to fever, respiratory distress, syncope, or decreased activity level in setting of recent viral illness.
What essential documentation is needed when deciding to reassure parents about an innocent murmur and discharge without cardiology referral?
Document all innocent murmur criteria present, complete normal cardiovascular exam findings, pertinent negative symptoms, parent discussion with education provided, and specific return precautions given.