chest pain case 4

Chest pain Case 4


A 45-year-old man presents with a 3-day history of persistent, severe chest pain. Prior to this, he had flu-Iike symptoms for 2 weeks, including
fever, cough, myalgias, and arthralgias. His pain is worse when he takes a deep breath and is improved when he sits up. On physical
examination, he is febrile, and his pulse is 110/min. His oxygen saturation is normaI, and his breath sounds are equal and clear to
auscultation over all lung fields. There is a scratching and scraping, high-pitched sound on auscultation of the heart over the left third
intercostal space, which is increased when the patient is sitting forward.



Question 1 of 4
Which of the following is the most likely diagnosis?
/ A. Acute pericarditis
/ B. Aortic dissection
/ C. Pneumonia
/ D. Pulmonary embolus
/ E. Tension pneumothorax



Question 2 of 4
Which of the following would help confirm the diagnosis?
/ A. Angiogram showing a clot in one of the coronary arteries
/ B. Chest radiograph showing multiple emphysematous bullae
/ C. CT scan of the chest showing a widened mediastinum
/ D. EIectrocardiogram showing diffuse ST elevation
/ E. Endoscopy revealing esophageal varices


Question 3 of 4
Other than an antecedent viral syndrome, which of the following conditions can predispose a patient to this problem?
/ A. AIcohol abuse
/ B. Liver failure
/ C. Peptic ulcer disease
/ D. Recent total hip replacement
/ E. Renal failure


Question 4 of 4
The patient is treated with a nonsteroidal anti-inflammatory agent. Which of the following was prescribed?
/ A. AIIopurinol
/ B. Gemfibrozil
/ C. Indomethacin
/ D. Labetalol
/ E. Methocarbamol


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Chest pain Case 4 answers


Q1
The correct answer is A. This patient has symptoms that are typical of inflammation of the pericardial sac. In addition, the sound that is heard over his heart is a pericardial friction rub. Acute pericarditis is often associated with viral syndromes, connective tissue diseases, renal failure, myocardial infarction, and tumor invasion of the pericardium.
Aortic dissection (choice B) will also present with severe chest pain, but it is tearing in quality, and is not positional, nor pleuritic in nature.
Pneumonia (choice C) may present similarly, but auscultation of the lung fields should reveal abnormal breath sounds, and a pericardial friction rub should not be heard.
Pulmonary embolus (choice D) can present with chest pain that is worse with deep breaths. However, it is not positional in nature, and it is not associated with a pericardial friction rub. Depending on the size of the embolus, the oxygen saturation may be abnormal.
Tension pneumothorax (choice E) is not associated with flu-like symptoms nor a pericardial friction rub. Furthermore, there should be an absence of breath sounds over the affected part of the lung.


Q2
The correct answer is D. Acute pericarditis often presents with diffuse ST elevation on an electrocardiogram.
An angiogram showing a clot in one of the coronary arteries (choice A) would be seen in a patient having an acute myocardial infarction.
A chest radiograph showing multiple emphysematous bullae (choice B) would be seen in a chronic smoker, and would be a possible cause of spontaneous pneumothorax.
CT scan of the chest showing a widened mediastinum (choice C) would be seen in a patient with an acute aortic dissection.
Endoscopy revealing esophageal varices (choice E) is seen in patients with chronic liver disease or portal hypertension.


Q3
The correct answer is E. Patients with renal failure or uremia can often present with a fibrinous or serofibrinous pericarditis.
Alcohol abuse (choice A) and liver failure (choice B) do not necessarily predispose a patient to pericarditis, nor are they associated with pericarditis.
Peptic ulcer disease (choice C) may cause epigastric pain that can be confused with chest pain, and patients may have recurrent bleeding, but this disorder is not associated with pericarditis.
A recent total hip replacement (choice D) predisposes patients to the development of a deep venous thrombosis, which can embolize and cause a pulmonary embolus. This is not associated with pericarditis.


Q4
The correct answer is C. Indomethacin or any of the other nonsteroidal anti-inflammatory agents can be used in the treatment of acute pericarditis.
Allopurinol (choice A) is used for the treatment of gout. It inhibits xanthine oxidase, which decreases the production of uric acid.
Gemfibrozil (choice B) is a lipid lowering agent used in patients with hypercholesterolemia.
Labetalol (choice D) is a beta blocker and is used in hypertensive emergencies.
Methocarbamol (choice E) is a muscle relaxant, which helps to relieve pain associated with muscle spasms.