Case presentationCase presentation

KHALID ALRASHDIKHALID ALRASHDI

R3R3

--case studycase study

--diagnosisdiagnosis

--home massagehome massage

Seen at 8:20 amSeen at 8:20 amMiddle age male presents with h/o Middle age male presents with h/o

chest pain since 3 dayschest pain since 3 days..

Primary surveyPrimary survey::Oriented , alert with some chest painOriented , alert with some chest pain

A- patentA- patentB- good b/l air entry, rr:20/minB- good b/l air entry, rr:20/min

C- bp:137/76 pr:114/min spo2:96%C- bp:137/76 pr:114/min spo2:96%D- GCS:15/15 RBS:6.2D- GCS:15/15 RBS:6.2

Middle age laborerMiddle age laborernot known to have any medical problemsnot known to have any medical problems not a smoker or ethanol consumernot a smoker or ethanol consumer..no family history of heart diseaseno family history of heart disease..Referred from Rusayl health center with Referred from Rusayl health center with ====================================================Gave a 3 day hGave a 3 day h//o of on and off pricking o of on and off pricking chest pain that is alternates between the rt chest pain that is alternates between the rt and lt side of the chestand lt side of the chest. . Is not associatd with Is not associatd with sweating, nausea or dizzinesssweating, nausea or dizziness. . no particular no particular radiation or relation to exertion or restradiation or relation to exertion or rest..

The pain was particularly severe starting 11 The pain was particularly severe starting 11 pm last nightpm last night. . He went to LHC in the early He went to LHC in the early hours of the morning hours of the morning . . He received aspirin He received aspirin 81 mg and and s81 mg and and s//l GTN after which the l GTN after which the pain somewhat subsided and he was pain somewhat subsided and he was reffered to SQUHreffered to SQUH..

Denies hDenies h//o fever, dizziness, SOB, orthopnea, o fever, dizziness, SOB, orthopnea, PND or coughPND or cough no urinary or gastroinestinal complaintsno urinary or gastroinestinal complaints..

Secondary surveySecondary survey::Head and neck:nadHead and neck:nad

CVS:S1S2CVS:S1S2P/A:softP/A:soft

CNS:NADCNS:NADECGECG

Lab investigationsLab investigations::

--CBC; hb 14, plt 355, WBC 12.2, ANC:9.7CBC; hb 14, plt 355, WBC 12.2, ANC:9.7

--U&E,LFT,BONE PROFILE:NADU&E,LFT,BONE PROFILE:NAD

--TROPONIN:NEGATIVETROPONIN:NEGATIVE

The ECG was shown to and dThe ECG was shown to and d//w Drw Dr. . MeharMehar. . since the patient is pain free and currently since the patient is pain free and currently stable, he opted for thrombolysing the stable, he opted for thrombolysing the

patientpatient.. - -

--thrmbolyse with reteplase 10 units ad thrmbolyse with reteplase 10 units ad repeat another 10 units after 10 minrepeat another 10 units after 10 min - - -enoxaprin and continue aspirin 81 mg -enoxaprin and continue aspirin 81 mg and clopidogrel 75 mg odand clopidogrel 75 mg od - - Admit to CCUAdmit to CCU--

repated ecg still showed st elevation in repated ecg still showed st elevation in anterior leadsanterior leads..

PlanPlan::

For angio+/-ptcaFor angio+/-ptca

Angio NORMAL CORONARIES GOOD LV Angio NORMAL CORONARIES GOOD LV FUNCTIONFUNCTION..

Impression Impression : : Chets pain with Normal Chets pain with Normal Coronaries with good LV function and Coronaries with good LV function and normal serial troponinsnormal serial troponins

? ?PericarditisPericarditis-- -Possible pneumonia left upper zone-Possible pneumonia left upper zone

PlanPlan --stop all antiplatelets and heparinstop all antiplatelets and heparin

-Continue augmentin and -Continue augmentin and azithromycinazithromycin-Check repeat CBC ESR Blood -Check repeat CBC ESR Blood cultures and CRP and ESRcultures and CRP and ESR-respiratory review-respiratory reviewECHO routineECHO routine--

PericarditisPericarditis

Pericarditis can be classified according to Pericarditis can be classified according to the composition of the inflammatorythe composition of the inflammatory exudateexudate..Types includeTypes include::serousserous purulentpurulent fibrinousfibrinous caseouscaseous hemorrhagichemorrhagic Post infarctionPost infarction

ClinicallyClinically: : Acute (<6 weeks), Acute (<6 weeks), Subacute (6 weeks to 6 months) Subacute (6 weeks to 6 months)

Chronic (>6 months). Chronic (>6 months).

CausesCauses::

--infectionsinfections

Viral 1-childrenViral 1-children coxsackieviruscoxsackievirus

22--adults adults cytomegaloviruscytomegalovirus, , herpesvirusherpesvirus, , andand HIVHIV..

Bacteria Bacteria PneumococcusPneumococcus or tuberculous or tuberculous

FungalFungal histoplasmosishistoplasmosis

in immunocompromised in immunocompromised AspergillusAspergillus, , CandidaCandida, and, and CoccidioidesCoccidioides..

IdiopathicIdiopathic : :No identifiable etiology found after routine No identifiable etiology found after routine testingtesting . .

ImmunologicImmunologic conditions including conditions including lupus erythematosuslupus erythematosus (more common among (more common among

women) orwomen) or rheumatic feverrheumatic fever Myocardial InfarctionMyocardial Infarction( ( Dressler's syndromeDressler's syndrome ) )

TraumaTrauma to the heart, e.g. puncture, resulting in to the heart, e.g. puncture, resulting in infection or inflammationinfection or inflammation

UremiaUremia( ( uremic pericarditisuremic pericarditis ) )MalignancyMalignancy( ( as aas a paraneoplastic phenomenonparaneoplastic phenomenon ) )

Side effectSide effect of some of some medicationsmedications, e.g, e.g . .isoniazidisoniazid , ,cyclosporinecyclosporine , ,hydralazinehydralazine

RadiationRadiation inducedinduced Aortic dissectionAortic dissection TetracyclinesTetracyclines Postpericardiotomy syndromePostpericardiotomy syndrome

ComplicationsComplications::

--Pericardial effusionPericardial effusion

--Constrictive pericarditisConstrictive pericarditis

--Cardiac tamponadeCardiac tamponade

TreatmentTreatment::

- -NSAIDNSAID

--pericardiocentesispericardiocentesis

--antibioticsantibiotics

--steroidssteroids

--colchicinecolchicine

in rare cases, surgeryin rare cases, surgery

HOME MASSAGEHOME MASSAGE::

- -there are more than ten causes for ST there are more than ten causes for ST elevationelevation

--MI -pericarditisMI -pericarditis--LVH -hyperkalemiaLVH -hyperkalemia

--myocardium disorder -acute cor pulmonalemyocardium disorder -acute cor pulmonale--post cardiac injury syndromepost cardiac injury syndrome

--cadiac truma -myocardial contusioncadiac truma -myocardial contusion--dresslers syndrome –aortic disectiondresslers syndrome –aortic disection

--early repolarization ECG syndromeearly repolarization ECG syndrome