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Category: Critical Care Medicine-Cardiovascular Disorders--->Pericardial Diseases
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Question 1# Print Question

A 35-year-old male with no significant past medical history presents to the Emergency Department with one day of worsening chest pain. The chest pain was abrupt in onset, is described as “sharp” in nature, and worsens with inspiration. It is primarily centered in the center of his chest but occasionally radiates to the left upper back. He feels that the pain worsens when he lays down. Vital signs are unremarkable including equal bilateral upper extremity blood pressures and radial pulses. On physical examination, he is febrile to 38.2°C. A triphasic “scratching” sound in time with the cardiac cycle is auscultated at the left lower sternal border. Initial laboratory studies show a negative troponin T and mild elevations in white blood cell count and the C-reactive protein. His ECG is shown below:

Which of the following is the most appropriate next step:

A. Heparin bolus and drip
B. High-dose aspirin and colchicine
C. Corticosteroids
D. Computed tomography angiography of the chest
E. Coronary angiography

Question 2# Print Question

A 51-year-old male with a recent history of acute pericarditis 6 weeks ago now resents with new onset chest pain. He stopped high-dose ibuprofen 4 weeks ago and has been feeling well since then. The chest pain started 12 hours ago, is very sharp, substernal, and pleuritic in nature. The symptoms are similar to his prior episode of pericarditis. He denies palpitations, lightheadedness, orthopnea, shortness of breath, and lower extremity edema.

On physical examination:

  • he is afebrile
  • pulse of 104 beats per minute
  • blood pressure 134/68 mm Hg
  • room air oxygen saturation of 99%

He has an audible friction rub. Kussmaul sign and jugular venous distension are absent. Laboratory evaluation reveals two negative serial troponin values, normal white blood cell count and creatinine, and mildly elevated C-reactive protein. ECG has nonspecific changes without ST-segment elevation. Echocardiogram shows normal biventricular function, no wall motion abnormalities, and a trace pericardial effusion that was previously visualized as well.

What is the most appropriate next therapy?

A. Heparin bolus and drip
B. Corticosteroids
C. Broad spectrum antibiotics
D. High dose ibuprofen and colchicine
E. Anakinra

Question 3# Print Question

A 62-year-old woman with a history of acute pericarditis 4 years ago that was treated with nonsteroidal anti-inflammatory drug (NSAID) to complete resolution presents with 8 weeks of insidiously worsening fatigue, bilateral lower extremity edema, breathlessness, and a feeling of abdominal fullness. She denies any fevers, chest pain, palpitations, or light-headedness. Physical examination is remarkable for 2+ pitting bilateral lower extremity edema, elevated jugular venous pressure with a rapid y descent, and an early diastolic sound best heard at the apex. Echocardiography shows normal right and left ventricular systolic function, a thickened pericardium without pericardial effusion, moderate left-sided pleural effusion, inspiratory ventricular septal motion toward the left ventricle, along with marked dilatation and absent respirophasic collapse of the inferior vena cava and hepatic veins.

The therapy most likely to yield relief of the patient’s symptoms is:

A. High-dose NSAIDs and colchicine
B. Corticosteroids
C. Percutaneous coronary intervention
D. Pericardiectomy
E. Reassurance

Question 4# Print Question

A 44-year-old woman with a past medical history of asthma presents with acute onset chest pain of 2 hours duration. She reports being in her usual state of health until the morning, when she had acute onset of sharp substernal chest pain. The pain is sharp, does not radiate, and has an intensity of 8/10. It is worse when she leans forward. She does not have any associated shortness of breath, nausea, palpitations, or light-headedness. She denies any recent long car rides or airplane trips. Her son is recovering from an upper respiratory infection.

Vital signs include:

  • temperature of 38.1°C
  • heart rate of 105 beats per minute
  • blood pressure of 124/72 mm Hg
  • room air oxygen saturation of 99%

On physical examination, she has normal heart sounds without any murmurs, friction rub, or S3 or S4. There is no jugular venous distension. Laboratory findings are remarkable for a troponin T of 0.03 ng/dL (normal <0.01), d-dimer <500 ng/mL, leukocytosis to 14,000/ µL, creatinine 0.78 mg/dL, and CRP 3.5 mg/L. ECG shows nonspecific changes without evidence of active ischemia. Echocardiography shows a small pericardial effusion and normal biventricular function without wall motion abnormalities.

What is the best next step in the management of this patient?

A. Send home with close follow-up with primary care physician
B. Admit to hospital for heparin bolus and drip
C. Admit to hospital for observation, high-dose NSAIDs, and colchicine
D. Activate cardiac catheterization laboratory for coronary angiography immediately
E. Admit to hospital for exercise stress testing

Question 5# Print Question

A 67-year-old male with history of former smoking, hypertension, diabetes, and stage III small cell lung cancer (on chemotherapy) presents to the Emergency Department with 3 days of progressive shortness of breath and an episode of syncope.

Vital signs show:

  • temperature of 36.6°C
  • regular heart rate of 130 beats per minute
  • room air oxygen saturation of 94%

Blood pressure at rest is 96/54 mm Hg at end inspiration and drops to 82/50 mm Hg with inspiration. Physical examination reveals a pale cachectic and uncomfortable appearing male with cool extremities, muffled heart sounds, and jugular venous pressure of 14 cm H2O.

Laboratory studies are remarkable for:

  • creatinine 2.5 mg/dL (baseline 1.0)
  • hemoglobin 7.5 g/dL (baseline 8.0)
  • platelets 120,000/µL
  • white blood cell count 13,000/µL
  • CRP 4.2 mg/L
  • troponin T 0.1 ng/dL
  • NT proBNP 8,000 pg/mL (no known baseline)

Precordial leads from his ECG are shown in the figure that follows:

What is the appropriate next diagnostic step?

A. Limited echocardiogram
B. CTA of the chest and abdomen (arterial phase)
C. Coronary angiography
D. CT chest pulmonary embolism protocol
E. Cardiac MRI

Category: Critical Care Medicine-Cardiovascular Disorders--->Pericardial Diseases
Page: 1 of 1