PERICARDITIS BASICS
MORE PERICARDITIS
PERICARDIAL EFFUSIONS
MYOCARDITIS
CARDIOMYOPATHIES
100
UP TO THIS AMOUNT OF FLUID IS NORMALLY CONTAINED IN THE PERICARDIAL SPACE
35 ML
100
IN A DIALYSIS PATIENT, CARDIAC ENLARGEMENT ON CXR IN THE ABSENCE OF SIGNS OF VOLUME OVERLOAD OR CHF SHOULD PROMPT CONSIDERATION OF ____
PERICARDIAL EFFUSION
UREMIC PERICARDITIS WILL PRESENT WITH CHEST PAIN, UNEXPLAINED FEVER, POSSIBLY COARSE FRICTION RUB
UREMIC PERICARDIAL EFFUSIONS ARE AMONG MOST COMMON CAUSES OF CARDIAC TAMPONADE - OFTEN LOCULATED AND HARD TO DRAIN
TREATMENT FOR UREMIC PERICARDITIS IS?
100
NAME 3 CAUSES OF PERICARDIAL EFFUSION
VIRAL OR IDIOPATHIC PERICARDITIS, MALIGNANCY, UREMIA, TRAUMA, RADIATION THERAPY
100
____ IS THE MOST COMMON PRESENTING COMPLAINT FOR MYOCARDITIS IN CHILDREN
DYSPNEA
ADULTS WILL HAVE DYSPNEA ALONG WITH CHEST PAIN AND POSSIBLY DYSRHYTHMIAS
CHILDREN MAY HAVE GRUNTING AND/OR RETRACTIONS ON EXAM WITH CLEAR LUNG SOUNDS
100
THIS CARDIOMYOPATHY WILL PRESENT WITH HEART FAILURE SYMPTOMS IN BOTH ADULTS AND CHILDREN
DILATED CARDIOMYOPATHY
ISCHEMIC CARDIOMYOPATHY SECONDARY TO CAD IS MC NON-GENETIC CAUSE OF DCM
200
CHEST PAIN, PERICARDIAL FRICTION RUB, EKG ABNORMALITIES ARE CLASSIC SYMPTOMS OF THIS
PERICARDITIS
200
FEVER, PLEURITIS, LEUKOCYTOSIS, PERICARDIAL FRICTION RUB, CXR SHOWING NEW PERICARDIAL EFFUSION OR PLEURAL EFFUSION IN POST-MI PATIENT IS CONCERNING FOR ____
DRESSLER'S SYNDROME OR POST-MI PERICARDITIS
OCCURS 2-8 WEEKS POST-MI
MAY OCCUR WITH PULMONARY EMBOLUS
RISK OF HEMORRHAGE WITH ANTICOAGULATION
TREATED WITH NSAIDS
200
A MINIMUM OF ____ ML OF FLUID IS NECESSARY TO SEE A PERICARDIAL EFFUSION ON CXR
250 ML
WHAT IS THE DIAGNOSTIC MODALITY OF CHOICE FOR PERICARDIAL EFFUSION?
200
TRUE/FALSE, TACHYCARDIA DISPROPORTIONATE TO TEMP OR APPARENT TOXICITY IS A SPECIFIC FINDING
FALSE
EITHER ONE OF THESE MAY BE THE ONLY FINDING ON EXAM, BUT THEY ARE NON-SPECIFIC
200
A 19 YEAR OLD MALE SUDDENLY DROPS DEAD WHILE PLAYING BASKETBALL. THE PATIENT LIKELY HAD THIS AUTOSOMAL DOMINANT CONDITION AND DIED FROM THIS TYPE OF ARRHYTHMIA
VENTRICULAR TACHYARRHYTHMIAS - V FIB, V TACH
HYPERTROPHIC CARDIOMYOPATHY
ASSOCIATED WITH A LOUD CRESCENDO-DECRESCENDO MURMUR WHICH WILL DECREASE WITH INCREASES IN PRELOAD OR AFTERLOAD
ASIDE FROM SUDDEN DEATH DURING EXERTION, 90% WILL COMPLAIN OF SHORTNESS OF BREATH, OTHER SYMPTOMS INCLUDE ORTHOPNEA, EDEMA CHEST PAIN, SYNCOPE, NEAR-SYNCOPE, PALPITATIONS
300
PERICARDITIS CHEST PAIN VARIES WITH POSITION, AND IS TYPICALLY RELIEVED BY ____ AND WORSENED BY ____
SITTING FORWARD
LYING DOWN, DEEP INSPIRATION, SWALLOWING
PERICARDIAL PAIN USUALLY RETROSTERNAL, CAN RADIATE TO TRAPEZIUS, CAUSE ISOLATED SHOULDER PAIN, MAY HAVE DIAPHRAGMATIC PAIN
300
TRUE/FALSE, PERICARDITIS MAY OCCUR AFTER CHEST TRAUMA NOT INVOLVING THE HEART OR PERICARDIUM
TRUE
TYPICALLY OCCURS 4-12 DAYS AFTER INJURY
300
____ IS THE MOST IMPORTANT FACTOR IN THE DEVELOPMENT OF CARDIAC TAMPONADE
RATE OF FLUID ACCUMULATION
AS LITTLE AS 150 ML OF FLUID MAY CAUSE TAMPONADE
3 STAGES IN DEVELOPMENT OF TAMPONADE
1. FLUID FILLS RECESSES OF PARIETAL PERICARDIUM
2. FLUID ACCUMULATES FASTER THAN PARIETAL PERICARDIUM'S ABILITY TO STRETCH
3. FLUID ACCUMULATES FASTER THAN BODY'S ABILITY TO INCREASE BLOOD VOLUME TO SUPPORT RV FILLING PRESSURE
THIS ALL LEADS TO INCREASED PERICARDIAL PRESSURE, CAUSING DECREASED VENTRICULAR COMPLIANCE AND DECREASED BLOOD FLOW INTO HEART
WHAT IS THE HEART'S COMPENSATORY MECHANISM IN TAMPONADE?
300
TRUE/FALSE, INFANTS OFTEN HAVE A FULMINANT SYNDROME CHARACTERIZED BY FEVER, CYANOSIS, RESPIRATORY DISTRESS, TACHYCARDIA, CARDIAC FAILURE
TRUE
300
- Left ventricular hypertrophy with increased precordial voltages and non-specific ST segment and T-wave abnormalities
- Deep, narrow (“dagger-like”) Q waves in lateral (I, aVL, V5-6) +/- inferior (II, III, aVF) leads
WOULD YOU GIVE NITRO TO THIS PATIENT IF THEY PRESENTED WITH CHEST PAIN? WHY OR WHY NOT?
400
THIS IS THE "HALLMARK" PHYSICAL EXAM FINDING OF PERICARDITIS AND IS BEST HEARD WITH THE PATIENT IN THIS POSITION
PERICARDIAL FRICTION RUB
LEANING FORWARD IN FULL EXPIRATION
400
TRUE/FALSE, HEPATOCELLULAR CARCINOMA IS A COMMON CAUSE OF NEOPLASTIC PERICARDIAL DISEASE
FALSE
LUNG CANCER, BREAST CANCER, LYMPHOMA, LEUKEMIA
MALIGNANT EFFUSIONS MAY CAUSE TAMPONADE IN LATE DISEASE PHASE, BUT PATIENT'S QUALITY OF LIFE MAY BE IMPROVED IF TREATED PROMPTLY
400
TRUE/FALSE, HYPOTENSION, DISTENDED NECK VEINS AND MUFFLED HEART SOUNDS WILL ALWAYS BE PRESENT WITH TAMPONADE
FALSE
MAY BE ABSENT IF TAMPONADE DEVELOPS QUICKLY
WHAT IS THIS TRIAD CALLED?
400
NAME 2 EKG CHANGES COMMONLY ASSOCIATED
SINUS TACHYCARDIA, WIDE QRS, LOW VOLTAGE
PROLONGED QT, AV BLOCK, ACUTE MI PATTERN ALL POSSIBLE BUT LESS COMMON
EKG CHANGES MAY EXTEND BEYOND THE DISTRIBUTION OF A SINGLE CORONARY ARTERY
400
SYMPTOMS OF THIS CARDIOMYOPATHY INCLUDE EXERCISE INTOLERANCE, PERIPHERAL EDEMA, PULMONARY EDEMA, S3 AND S4 GALLOPS
RESTRICTIVE CARDIOMYOPATHY
CAUSES DIASTOLIC DYSFUNCTION DUE TO RESTRICTED VENTRICULAR FILLING
500
THIS IS THE MOST RELIABLE DIAGNOSTIC TOOL FOR PERICARDITIS
EKG
500
CORTICOSTEROID THERAPY IS THE TREATMENT OF CHOICE FOR PERICARDITIS IN THIS CATEGORY OF DISEASE
AUTOIMMINUE DISORDERS
1/3 OF PEOPLE WITH RA WILL DEVELOP PERICARDITIS WITHIN 3 YEARS OF RA DIAGNOSIS
MOST AUTOIMMUNE DISORDERS MAY LEAD TO PERICARDITIS
500
ELECTRICAL ALTERNANS
500
A 35 YEAR OLD MARATHON RUNNER WITH NO MEDICAL HISTORY PRESENTING WITH NEW ONSET CHF SYMPTOMS SHOULD PROMPT CONSIDERATION FOR ____ AS A CAUSE
MYOCARDITIS
CONSIDER IN YOUNG, HEALTHY PATIENTS WITH SIGNS OF NEW ONSET CHF OR DYSRHYTHMIAS
500
A FEMALE WHO IS 8 MONTHS PREGNANT PRESENTS WITH SHORTNESS OF BREATH, PERIPHERAL EDEMA AND HAS PULM EDEMA ON CXR. THEY MOST LIKELY HAVE THIS
PERIPARTUM CARDIOMYOPATHY
OCCURS DURING LAST 3 MONTHS OF PREGNANCY AND UP TO 5 MONTHS POSTPARTUM
600
STEMI
600
____ AND ____ CAUSES OF PERICARDITIS CAN COEXIST
VIRAL AND BACTERIAL
VARICELLA-ZOSTER SUPER-INFEFECTED WITH STAPH AUREUS FOR EXAMPLE, MORE COMMON IN CHILDREN
600
____ IS THE TREATMENT OF CHOICE FOR CARDIAC TAMPONADE
PERCIARDIOCENTESIS/PERICARDIAL WINDOW
WHILE YOU PREP TO PERFORM A PERICARDIOCENTESIS THE PATIENT SHOULD BE RECEIVING ____ IN THE MEANTIME
600
TRUE/FALSE, STABLE PATIENTS WITH SUSPECTED MYOCARDITIS SHOULD BE DISCHARGED HOME
FALSE
ADMIT FOR MONITORING AND FURTHER WORKUP
600
A 35 YO MALE PRESENTS WITH NEAR SYNCOPE AND PALPITATIONS ON AND OFF FOR 2 DAYS. HE HAS NO PMH. HE IS ESTRANGED FROM HIS FAMILY BECAUSE HIS PARENTS TOOK AWAY HIS STASH OF NUDEY MAGS AND CIGARETTES ONCE IN HIGH SCHOOL, BUT THINKS HE HAD 1 OR 2 RELATIVES DIE FROM SOME SORT OF EARLY CARDIAC DEATH. WHAT DISORDER DOES HE HAVE AND WHAT IS HIS CURRENT RHYTHM?
HCM WITH AFIB
HIS INITIAL BP IS 140/85. WHAT DO YOU WANT TO DO?
LET'S SAY HIS PRESSURE DROPPED TO 80/40 WHILE YOU WERE SOILING YOURSELF TRYING TO MAKE A DECISION?
YOU FINALLY MADE A DECISION, BUT HE'S PERSISTENTLY HYPOTENSIVE DESPITE RHYTHM IMPROVEMENT (YOU'VE NOW COMPLETELY EVACUATED YOUR BLADDER AND BOWELS AND ARE ON THE VERGE OF A PSEUDOSEIZURE). WHAT PRESSOR WOULD BE PREFERRED?
700
DIFFUSE ST ELEVATION IN LEADS I, II, III, AVL, AVF, V2 - V6
ST DEPRESSION IN AVR, V1
CONCURRENT PR DEPRESSION
700
A CCMH HOSPITALIST BOUNCEBACK ARRIVES TO THE DREWRY FAMILY EMERGENCY CENTER 1 DAY AFTER BEING DISCHARGED FOLLOWING TREATMENT FOR SEPSIS DUE TO PNEUMONIA. THEY ARE A CIRRHOTIC DIALYSIS PATIENT WITH CHF AND DIABETES WHO ARE ALSO ON AN IMMUNOLOGIC FOR CROHN'S DISEASE. THEY COMPLAIN OF FEVER, DYSPNEA AND CHEST PAIN. THEY HAVE A PERICARDIAL EFFUSION ON BEDSIDE US. WHAT TYPE OF PERICARDITIS SHOULD BE CONSIDERED?
PRURULENT PERICARDITIS
MOST COMMON PRESENTATION IS HOSPITALIZED PATIENT WITH SEVERE UNDERLYING DISEASE WHO INITIALLY IMPROVES AFTER TREATMENT OF PRIMARY INFECTIOUS PROCESS BUT LATER DEVELOPS FEVER, DYSPNEA AND CHEST PAIN
ASSOCIATED WITH HIGH MORTALITY
700
A 36 YEAR OLD HONDURAN MIGRANT FEMALE PRESENTS TO THE DREWRY FAMILY EMERGENCY CENTER WITH COMPLAINTS OF SYNCOPE, CHEST PAIN AND FEVER. ON EXAM YOU NOTICE UNILATERAL PERIORBITAL EDEMA. SHE HAS MULTIPLE PVC'S ON HER EKG. WHILE ON THE MONITOR SHE HAS SEVERAL RUNS OF NON-SUSTAINED VTACH. YOU SHOULD CONSIDER THIS AS THE SOURCE OF HER SYMPTOMS.
CHAGAS' DISEASE
CAUSED BY TRYPANOSOMA CRUZI
SYSTEMIC SYMPTOMS INCLUDE FEVER, HEPATOSPLENOMEGALY, UNILATERAL PERIORBITAL EDEMA, EMBOLIC EPISODES, HEART FAILURE, CONDUCTION ABNORMALITIES, PVC'S, ST AND T WAVE ABNORMALITIES
V TACH IS COMMON AND PRE-SYNCOPE/SYNCOPE OCCURS IN ALMOST 2/3 OF PATIENTS
700
A 28 FEMALE WHO IS CURRENTLY 37 WEEKS WITH CHILD PRESENTS WITH SHORTNESS OF BREATH, CHEST PAIN, ORTHOPNEA AND LE SWELLING WORSENING FOR THE PAST 4 DAYS. SHE IS EDEMATOUS AND HAS RALES ON EXAM. BP IS 180/95. VITALS ARE OTHERWISE OKAY. GIVE 3 DIFFERENTIALS.
PERIPARTUM CARDIOMYOPATHY, PRE-ECLAMPSIA, PE, MYOCARDIAL ISCHEMIA
HOW WOULD YOU TREAT THIS PATIENT?
WHAT MEDICATION COULD YOU GIVE TO BRING HER PRESSURE DOWN? WILL IT HELP WITH PRELOAD OR AFTERLOAD?
800
THIS EKG FINDING IS NOT SEEN IN THE ACUTE PHASE OF PERICARDITIS, BUT MAY BECOME PERMANENT ONCE PERICARDITIS RESOLVES
T WAVE INVERSION
YOU WILL ALSO NOT SEE Q WAVES ASSOCIATED WITH PERICARDITIS
800
A 30 YEAR OLD SOUTH AFRICAN EXPAT WHO HAD BEEN A VAGRANT LIVING ON THE STREETS OF JOHANNESBURG MAKES IT TO THE DREWRY FAMILY EMERGENCY CENTER AT CCMH. HE PRESENTS WITH CHEST PAIN, FEVER AND SHOB. HIS CXR SHOWS AN ENLARGED CARDIAC SILHOUETTE W/O PULMONARY INFILTRATES. WHAT SHOULD YOU BE WORRIED ABOUT AS THE CAUSE OF HIS PERICARDITIS?
TUBERCULOSIS
WHAT ELSE SHOULD HE BE TESTED FOR?
800
A 55 YEAR OLD MEXICAN MIGRANT ARRIVES TO THE DREWRY FAMILY EMERGENCY CENTER COMPLAINING OF CHEST PAIN AND DYSPNEA. AN INTERN GOES IN TO SEE HIM. AFTER SPENDING ALMOST HALF AN HOUR IN THE ROOM GETTING A THOROUGH HISTORY (IE, SMOKING PACK YEARS, LAST COLONSCOPY, ETC.) THEY FIND OUT HE HAS HAD RECENT FEVERS, MYALGIAS, NECK STIFFNESS, AND SWELLING AROUND HIS EYES. BECAUSE DR. INTERN WAS SO THOROUGH IN THEIR HISTORY TAKING THEY ALSO FIND OUT THE PATIENT WAS A PIG FARMER UNTIL RECENTLY. WHAT IS THE MOST LIKELY SOURCE OF HIS SYMPTOMS?
TRICHINOSIS
CARDIAC MANIFESTATIONS INCLUDE CHEST PAIN, DYSPNEA, CARDIOMEGALY, DYSRHYTHMIAS AND CHF
800
A 75 YEAR OLD FEMALE WITH A HX OF TOBACCO AND ETOH ABUSE PRESENTS WITH CHEST PAIN, DYSPNEA AND PALPITATIONS. SHE TELLS YOU HER HUSBAND OF 50 YEARS RECENTLY DIED AND SHE HAD TO SELL HER HOUSE TO PAY GAMBLING DEBTS. THIS IS HER EKG. WHAT DO YOU DO?
ACTIVATE THE CATH LAB AFTER YOUR ASTUTE RECOGNITION OF A STEMI.
THEIR TROPONIN AND BNP ARE ELEVATED.
THE CARDIOLOGIST CALLS YOU AFTER THEY'VE DONE THE CATH TO TELL YOU THERE WAS NOT SIGNIFICANT CAD. THEN HE SENDS YOU THIS PIC AND WANTS YOU TO TELL THEM WHAT THEY HAVE.
900
TRUE/FALSE, VENTRICULAR DYSRHYTHMIAS ARE COMMON IN PERICARDIAL DISEASE
FALSE, THEY ARE RARE
IF DYSRHYTHMIAS ARE PRESENT THEN CONSIDER CONCOMITANT MYOCARDITIS OR ANOTHER CARDIAC DISEASE
900
TRUE/FALSE, TENSION PNEUMOPERICARDIUM MANIFESTS WITH CLINICAL FINDINGS OF ACUTE CARDIAC TAMPONADE
TRUE
AFTER YOU HAVE EXCLUDED ALL OTHER LIFE THREATENING INJURIES/COMPLICATIONS CAN YOU DISCHARGE SOMEONE WITH UNCOMPLICATED SPONTANEOUS PNEUMOPERICARDIUM?
900
WHAT CARDIAC SCREENING TEST IS RECOMMENDED FOR A PATIENT WHO HAS HAD THIS RASH AND WHAT WOULD BE THE MOST COMMON ABNORMALITY SEEN?
EKG
MOST COMMON CARDIAC COMPLICATION IS CONDUCTION DELAY, USUALLY AT THE AV NODE (AV BLOCK)
900
A 30 YEAR OLD MARATHON RUNNER NAMED GIOVANNI LOMBARDI PRESENTS AFTER A SYNCOPAL EPISODE DURING A RACE. HE DEVELOPS PALPITATIONS AFTER COMING TO, AND COMES TO THE ED. HE LOSES CONSCIOUSNESS AS THEY GET HIM ON THE MONITOR. THIS IS WHAT YOU SEE. WHAT IS THIS AND WHAT DO YOU DO?
VTACH. CARDIOVERSION.
CARDIOVERSION IS SUCCESSFUL (GOOD JOB). HE IS NOW AWAKE AND TALKING TO YOU. THIS IS HIS REPEAT EKG.
WHAT DO YOU SEE? WHAT DOES HE HAVE?
1000
TRUE/FALSE, A NORMAL ECHOCARDIOGRAM CANNOT BE USED TO EXCLUDE PERICARDITIS
TRUE
ECHO MAY APPEAR NORMAL WITHOUT AN EFFUSION
1000
SIGNS/SYMPTOMS OF CONSTRICTIVE PERICARDITIS ARE THE SAME AS THOSE SEEN IN ____
CHF
DYPSNEA, FATIGUE, WEIGHT GAIN MC COMPLAINTS
CONSTRICTIVE PERICARDITIS MAY BE SEEN AS LATE SEQUELA OF ACUTE PERICARDITIS FROM ANY CAUSE
INCREASING IN INCIDENCE DUE TO INCREASED SURVIVAL OF PATIENTS WITH CKD
1000
DYSFUNCTION OF THIS HEART VENTRICLE IS SEEN IN 20% OF ADULT AIDS PATIENTS
LEFT VENTRICULAR DYSFUNCTION
CARDIAC INVOLVEMENT INCREASES AS DISEASE WORSENS, HIV TREATMENTS MAY CAUSE CARDIOTOXICITY, MANY OPPORTUNISTIC INFECTIONS (M. PNEUMONIA, TOXOPLASMA, CHAMLYDIA PNEUMONIAE) CAN CAUSE MYOCARDITIS
1100
NAME 5 CAUSES OF PERICARDITIS
INFECTIOUS - VIRAL, BACTERIAL, FUNGAL, PARASITE, RICKETTSIA
POSTINJURY - TRAUMA, SURGERY, MI, RADIATION
METABOLIC - UREMIA, MEDICATION
SYSTEMIC DISEASE - RA, SLE, SARCOIDOSIS, SCLERODERMA, DERMATOMYOSITIS, AMYLOIDOSIS
TUMORS
AORTIC DISSECTION
1200
THIS IS THE TREATMENT OF CHOICE
NSAIDS
IBUPROFEN FOR 1 WEEK
IF INEFFECTIVE TRY ANOTHER NSAID - INDOMETHACIN, NAPROXEN
CONSIDER COLCHICINE FOR RECURRENT EPISODES
STEROIDS ARE SECOND LINE, USED FOR PEOPLE WHO CAN'T TAKE NSAIDs OR WHO ARE ON ANTICOAGULANTS
1300
TRUE/FALSE, 60% WILL HAVE COMPLETE RECOVERY IN 1 WEEK, ALMOST 80% HAVE COMPLETE RECOVERY WITHIN 3 WEEKS
TRUE