Identifying Information:
Patient: J.D. 40 y/o BF.
DOB: 01/13/1973
Visit: 3/12/2013, 0900
Medical HX: Pt. was diagnosed with HTN, hyperlipidemia, and type II DM 10 years ago, all three are well controlled with medication, diet and exercise. Pt. was diagnosed with systemic lupus erythematosus two years ago and is currently not experiencing complications related to her disorder. She was taken off steroids six months ago and takes NSAIDS as needed. No other childhood or adult diseases, and immunizations UTD. She received the flu vaccination 12/2012. No psychiatric history.
Surgical HX: Pt. reports uncomplicated TVH (total vaginal hysterectomy) in 2011 due to symptomatic uterine fibroid tumors. Pt. denies any negative effects from this procedure.
OBGYN: G-1 T-1 P-0 A-0 L-1, TVH 2011
Medications: Lisinopril/HCTZ 20-12.5 mg PO daily
Metformin 500 mg PO twice daily
Lipitor 20 mg PO daily
Ibuprofen 600 mg every 6 hours as needed
Tylenol 1,000 mg every 6 hours as needed
Allergies: None.
Personal/social HX: Pt. works as a nurse at a local hospital 40-50 hrs/week. She has been divorced one year and lives at home with her 11-year-old daughter who is in good health. She is an active member in her church and has a good support system. She and her daughter joined a gym near their home about three months ago. She enjoys doing yoga and eating healthy. She is compliant with her recommended and prescribed diet, exercise and medication regimen.
Drugs, Alcohol, or Smoking HX: No illegal drug use, no alcohol or tobacco use.
Family HX: Father – HTN, doing well, Mother – hypothyroidism, doing well, Siblings – unremarkable
Source of information: Patient, seems reliable.
Subjective
CC: “I have a sharp pain, that feels like a knife is stabbing me on the left side of my chest.”
HPI: A 40-year-old black female presents with complaints of sharp, knifelike pain on the left side of her chest for the last two days. She rates her pain a 7 on the 0-10 pain scale, and she describes her pain as constant. Breathing and lying down make the pain worse, while sitting forward helps her pain. She denies any upper respiratory or GI symptoms, and also denies injury to the painful site. Tylenol and Ibuprofen have been unsuccessful in relieving her pain.
Review of systems:
General: Reports being “as healthy as she can be.” Denies fever, chills, recent weight gain or loss, weakness, or fatigue. States her last physical exam was in 2012, and first mammogram was in January of this year with normal results.
Skin, hair, & nails: Denies any changes in skin, hair and nails.
HEENT: head – denies injury or headaches, eyes – denies vision problems, last eye exam one year, ears – hearing good, no ear problems, nose – denies abnormal nasal conditions,
throat – denies any throat problems, last dental exam 1 year.
Thorax/lungs: Reports sharp, knifelike pain to the left side of chest, see HPI. Denies injury, lung disease, allergies, or asthma. Last chest x-ray 2012
Cardiovascular: Reports sharp, knifelike pain to the left side of chest, see HPI. Denies irregular heartbeat, palpitations, or murmurs. Reports HTN and hyperlipidemia. Last EKG 2012. No prior stress test.
PVS: Denies extremity edema, coldness, leg cramps, or ulcers.
Abdomen: Diabetic diet, denies N/V, bowel problems or pain. Denies history of jaundice, gallbladder, or liver disease.
GU: Denies urinary frequency, hesitancy, incontinence, nocturia, flank pain, burning, or bleeding with urination.
Metabolic/Hematologic: Reports type II DM, denies thyroid problems, heat/cold intolerance, bruising, ease of bleeding. No history of blood transfusions.
Musculoskeletal: Denies trauma or injury.
Psychiatric: Denies trouble concentrating, nervousness, anxiety, panic attacks, mood changes, hearing voices, frequent unhappiness, or desire to harm self/others. Sleep trouble related to nighttime coughing, no nightmares, memory loss, or excessive life stresses. No recent deaths in family or close friends.
Neurologic: Denies history of stroke, seizures, frequent/incapacitating headache, and tremors.
Objective:
Vital Signs: B/P-130/70, P-90, R-12, T-98.9, O2-99% Ht: 5’5”, Wt: 150 lbs., BMI: 25
General: Black female, well kept, AAOX3, good eye contact and speech. Appears to be in distress, leaning over holding her left arm and hand to her chest.
Hair: WNL, thick and evenly distributed with no breakage, alopecia, dryness, or infestations
noted. Hair appears shiny and red in color. Eyebrows and eyelashes present and evenly distributed.
Skin: Warm, dry, supple, no bruises, rashes, or suspicious nevi to exposed skin.
Nails: Smooth and well manicured without clubbing or cyanosis. Capillary refill to finger pad is brisk.
Head/Neck: Normocephalic/atraumatic, no bumps, bruises, lesions. Scalp pink and moist. No sinus tenderness, and no palpable lymph node enlargement or tenderness. Neck supple; thyroid isthmus palpable, lobes not felt. Trachea midline.
Eyes: Pupils 4mm constricting to 2mm, PERRLA, EOMI, negative strabismus and nystagmus, conjunctiva pink and moist.
Ears: Acuity good, no tenderness or abnormalities to tragus & pinna, ear canal without inflammation or cerumen noted bilaterally. TM pearly white and intact with no redness or bulging. Cone of light visible bilaterally (5 o’clock right, 7 o’clock left).
Nose: Turbinates intact, nares patent, no septal deviation, nasal flaring or discharge.
Throat/mouth: Membranes pink and moist. Uvula is midline, tonsils at pillars, no redness or exudates. Good dentition noted.
Lungs: Respirations 12 breaths/min, breath sounds vesicular, no rhonchi, wheezes, or crackles present. Lungs resonant. Thorax is symmetric, and the diaphragms descend 4 cm bilaterally.
Heart: Scratching noise heard at lower left sternal border, coincident with systole. Apical pulse 90 bpm on auscultation. S1 and S2 regular rate and rhythm with no splitting, S1 best at apex, S2 best at base, with no S3 or S4. Carotid upstrokes brisk with no bruits. No JVD. PMI palpable at 5th ICS 7cm lateral to the midsternal line, discrete and tapping. No heaves, lifts, or thrills. No rubs, gallops, murmurs, or opening snaps. Pain not elicited with chest wall palpation.
Breasts: Symmetric and smooth without masses. Nipples without discharge.
Abdomen: Normoactive BS x 4 quadrants. No abdominal bruits. Soft, flat, and non-distended with no scars or striae. No abdominal tenderness to palpation. No palpable masses or hepatosplenomegaly. Kidneys not felt, no CVA tenderness.
Lymph Nodes: Head, neck, axilla, epitrochlear, and inguinal lymph nodes nonpalpable.
Extremities: Extremities are warm without edema. No varicosities or stasis. Calves are supple and non-tender. No femoral bruits. Brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial pulse are all 2+ and symmetric. Full range of motion to all extremities.
Genitals: Deferred
Rectum/Anus: Deferred
Neurologic: AAOX3, and cooperative. Anxious d/t acute distress. Cranial nerves II-XII intact. Normal gait. Maintains balance with eyes closed. Good, even strength and muscle tone. Reflexes are 2+ and symmetric with plantar reflexes. Rapid alternating movements intact. Pinprick, light touch, position, and vibration intact.
Assessment:
- Diagnosis – Acute Pericarditis (This is an inflammation of the pericardium, the fibrous sac surrounding the heart. Symptoms include chest pain that is relieved by sitting up and bending forward and worsened by lying down or on inhalation. Often, the pain is described as “knifelike.” The pain may resemble the pain of angina pectoris, or heart attack, but differs due to pain changes with body position. Often, an extra heart sound called a “pericardial friction rub” is heard on auscultation due to inflammation of the pericardium. Pericarditis is common in patients with rheumatic diseases like systemic lupus erythematosus (McCance, 2010).)
- Differential diagnoses:
- Chronic Pericarditis
- Cardiac tamponade
- Differential diagnoses:
- Myocardial infarction
- Myocarditis
- Aortic stenosis
- Mitral valve prolapse
- Hypertrophic obstructive cardiomyopathy
- Costochondritis
- Biliary colic
- Gastritis
- GERD
- Aortic dissection
- Pulmonary embolism
- Pleural effusion
Plan:
- Administer O2 at 2L/min via NC.
- It is important to administer oxygen at this time while ruling out other life-threatening causes of chest pain (Spangler, 2012).
- Allow pt. to sit upright.
- Lying flat causes her a great deal of pain, while leaning forward relieves the pain (McCance, 2010).
- Attach/order cardiac monitor.
- must be monitored while ruling out other life-threatening causes of chest pain (Dunphy, 2011).
- Attach/order pulse oximetry.
- must be monitored while ruling out other life-threatening causes of chest pain (Dunphy, 2011).
- Administer Aspirin 325mg PO one dose.
- NSAID’s are the mainstay of therapy for acute pericarditis. Ibuprofen has been unsuccessful, will try aspirin, reevaluate, then consider adding colchicine or stronger pain medications (Spangler, 2012).
- Obtain a CBC count with a differential.
- Significant leukocytosis may be present with an either inflammatory or infective cause of pericarditis. Serially monitor hemoglobin and hematocrit values. Transfuse patient with a hemoglobin value of less than 8g because this improves the abnormalities of hemostasis associated with uremia. Monitor the platelet count (Spangler, 2012).
- Obtain a prothrombin time/activated partial thromboplastin time (PT/aPTT).
- If abnormal, these increase the chance of developing tamponade, must correct (Spangler, 2012).
- Obtain serum electrolyte (i.e., sodium, potassium, chloride, magnesium, calcium, phosphate) concentrations.
- Increased risk of cardiac arrhythmias in patients with pericarditis (Spangler, 2012).
- Obtain erythrocyte sedimentation rate (ESR) and c-reactive protein (CRP) levels.
- Levels are usually elevated in pericarditis. High-sensitivity CRP (hs-CRP) levels are elevated in 78% of cases of acute pericarditis. Thus, an elevated CRP level may confirm the diagnosis of acute pericarditis. A normal value does not exclude a diagnosis of acute pericarditis. In some patients, the hs-CRP increased later, supporting the use of serial testing in patients with an initial negative result. Most patients showed normalization of CRP level by 2 weeks and all patients by 4 weeks. A persistently elevated hs-CRP level was a marker for increased risk of reoccurrence. Serial monitoring of hs-CRP level weekly may be warranted to follow disease activity and guide the appropriate length of therapy, with continuation of treatment doses until the CRP level normalizes (Spangler, 2012).
- Obtain cardiac biomarkers.
- Evaluate cardiac biomarkers, such as creatine kinase and isoenzymes levels, as well as LDH and SGOT (AST) for associated myocarditis or myocardial infarction. Troponin I may be elevated in viral or idiopathic acute pericarditis (Spangler, 2012).
- Obtain chest x-ray.
- Patients with small effusions (less than a few hundred ml) may present with a normal cardiac silhouette. In one study, pleural effusions were seen in 33% of patients with pericarditis. Approximately 75% of the effusions were left-sided only. A flask-shaped, enlarged cardiac silhouette may be the first indication of a large pericardial effusion (200-250 mL of fluid accumulation) or cardiac tamponade (see the following image). This occurs in patients with slow fluid accumulation, compared with a normal cardiac silhouette seen in patients with rapid accumulation and tamponade. Thus, the chronicity of the effusion may be suggested by the presence of a huge cardiac silhouette (will not collect upt, pt. had TVH in 2011) (Spangler, 2012).
- Obtain an ECG (electrocardiogram).
- ECG can be diagnostic in acute pericarditis and evolves in 4 stages. However, only 50% of patients with pericarditis experience all 4 stages. An important ECG finding is PR-segment depression, which has been reported in as many as 80% of viral pericarditis cases. Electrical alternans is pathognomonic of cardiac tamponade and is characterized by alternating levels of ECG voltage of the P wave, QRS complex, and T waves. This is a result of the heart swinging in a large effusion (Spangler, 2012).
- Refer to Cardiovascular for echocardiogram.
- Echocardiography is recommended in all cases of pericarditis. Any form of pericardial inflammation can induce pericardial effusion. It is important to note that the pericardium may have a normal appearance in pericarditis, without evidence of fluid accumulation. M-mode is used to evaluate pericardial fluid and timing during the cardiac cycle; it demonstrates persistence of the echo-free space between the parietal pericardium and the epicardium during this cycle. Fluid is distributed from the posterobasal left ventricle apically and anteriorly, then laterally and posteriorly to the left atrium. Fluid adjacent to the right atrium is an early indicator of an effusion. Other causes of echo-free space that must be considered include: pleural effusion, pericardial masses, and epicardial fat. To a limited extent, an echocardiogram can characterize the effusion. Very small effusions are located posterior and inferior to the left ventricle. Moderate effusions extend toward the apex of the heart, and large effusions circumscribe the heart. Weitzman criteria define a moderate effusion as an echo-free pericardial space (anterior plus posterior) of 10-20mm during diastole and a large effusion as an echo-free space more than 20mm. A “swinging heart” may be present with large effusions (Spangler, 2012).
- Consult internal medicine for possible hospital admittance pending test results.
- may require hospitalization for further testing and treatment. A pericardiocentesis may be necessary (Spangler, 2012).
- Educate patient on pericarditis.
- It is important for the pt. to understand his or her disease process, signs and symptoms, causes, treatment options, and prognoses. Pericarditis is commonly seen in rheumatic diseases like systemic lupus erythematosus. This is important information pertaining to this case (McCance, 2010).
References
Bickley, L. S. (2009). Bates’ Guide to Physical Examination and History Taking (10th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2011). Primary Care: The Art and Science of Advanced Practice Nursing (3rd ed.). Philadelphia, PA: F.A. Davis.
McCance, K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2010). Pathophysiology The Biological Basis for Disease in Adults and Children (6th ed.). Maryland Heights, MO: Mosby Elsevier.
Spangler, S. J. (2012). Acute Pericarditis. Retrieved March 10, 2013, from http://emedicine.medscape.com/ article/156951