BYBY ::

AFDALIAAFDALIA

C111 0C111 077 1 11414

SUPERVISORSUPERVISOR ::

DR. PENDRIK TANDEAN, SPPD-KKV.FINASIMDR. PENDRIK TANDEAN, SPPD-KKV.FINASIM

ACUTE PERICARDITIS

Patient Identity

• Name : Mr. Y

• Age : 41 years old

• Address : Takallar Pattalasang

• Medical record : 536023

• Admitted : January 1th 2013

History Taking

Chief complaint: Chest painHistory taking: Experienced since 2 days ago before admitted to

the hospital, feel like stab and penetrate to the back. The patient feel comfortable when in bend position and the pain was not improved by rest. Shortness of breath (-) accompanied by sweating, nausea. PND (-), DOE (-)

Fever (+), since 2 days before admitted to the hospital, Headache (-)

Epigastric pain (-), Cough (-)No history of previous chest pain,Defecation & urination normal

History of illness

Hypertension history (-), DM (-), heart disease (-)

History of smoking (-) Post. Op urolithiasis December 2012

Physical Examination

• General Status :

Moderate-illness/normal Body

Weight/conscious

• Vital Sign : Blood Pressure : 110/70 mmHg Pulse : 88 bpm, regular Respiratory rate : 20 tpm,

abdominothoracal Body temperature : 36,8º C

Head Examination• Eyes : anemic -/-, icterus -/-• Lip : cyanosis (-)• Neck : lymphadenopathy (-), JVP R +2 cmH2O

Chest Examination• Inspection : symmetric R=L, normochest• Palpation : mass (-), tenderness (-), VF R=L• Percussion : sonor• Auscultation : breath sound : vesicular

additional sound : ronchi - /- wheezing -/-

Cardiac Examination

• Inspection : IC not visible• Palpation : IC not palpable • Percussion : Normal • Auscultation : Heart sound I/II regular,

murmur (-)

Abdominal Examination - Inspection : flat and following

breath movement- Auscultation : peristaltic sound (+) ,

normal- Palpation : liver and spleen

unpalpable- Percussion : tympani, ascites (-)

Extremities - Oedema : pretibial -/-

dorsum pedis -/-

Interpretation

- Rhythm : Sinus rythm- Hearth Rate : 85 x/minute- P wave : 0,08- PR Interval : 0,12 ms- QRS Complex : 0,08- Axis : Normoaxis- ST Segment : - L1+aVL = ST Depresion

- - II, III, aVF = ST Elevation Inferior

- - V1+V2 = ST Elevation Septal- - V3+V4 = ST Elevation Anterior- - V5+V6 = ST Elevation Lateral

Conclusion : Sinus rhythm, HR 85x/minute, normoaxis, ST elevation

mostly in all leads.

LABORATORY FINDINGS

(01/01/2013)

• Routine Blood Test

RBC : 4,40 x106/mm3

WBC : 24,1 x103/mm3

HB : 12,1 g/dlHCT : 37,41 %PLT :386.103/mm3

• Biochemical blood test

GDS : 118 mg/dl Ureum : 78 mg/dlCreatinin : 5,4 mg/dlSGOT : 24 U/L SGPT : 35 U/LTot.Chol: 96 mg/dl HDL : 6 mg/dlLDL : 32 mg/dl TG : 195 mg/dl

Electrolyte (01/01/2013) Sodium : 138 mmol/L Potassium : 4,4 mmol/L Chloride : 110 mmol/L

Cardiac Enzyme (03/01/2013) CK-MB : 151 U/L Trop. T : 1,5

WORKING DIAGNOSIS

CHEST PAIN e.c SUSPC. ACUTE PERICARDITIS

PLANNING

Thorax PAEchocardiography

MANAGEMENT

O2 2 L/minIVFD NaCl 0.9% 500cc/24h/ivCeftriaxone 2 gr/24h/ivIbuprofen 4x400 mg

Acute pericarditis

DEFINITION

•Acute pericarditis is an inflammation of the pericardium characterized by chest pain, pericardial friction rub, and serial electrocardiographic (ECG) changes (see an example of such an ECG below).

•Happened more man than woman

Causes

• Idiopathic (idio and pathy) – 86%Infective (viral or bacterial) – 7%Following a myocardial infarction or

cardiac surgery (Dressler’s syndrome)Radiation therapyNeoplastic disease (commonly lung or

breast) – 6%Connective tissue disease

PATHOPHYSIOLOGY

Pericardial tissue damaged by bacteria or other substances releases chemical mediators of inflammation (prostaglandins, histamines, bradykinins, and serotonin) into the surrounding tissue, thereby initiating the inflammatory process. Friction occurs as the inflamed pericardial layers rub against each other. Histamines and other chemical mediators dilate vessels and increase vessel permeability. Vessel walls then leak fluids and protein (including fibrinogen) into tissues, causing extracellular edema. Macrophages already present in the tissue begin to phagocytize the invading bacteria and are joined by neutrophils and monocytes. After several days, the area fills with an exudate composed of necrotic tissue and dead and dying bacteria, neutrophils, and macrophages. If the cause of pericarditis isn't infection, the exudate may be serous (as with autoimmune disease) or hemorrhagic (as seen with trauma or surgery). Eventually, the contents of the cavity autolyze and are gradually reabsorbed into healthy tissue.

RISK FACTORS

Pericarditis occurs in people of all ages. However, men between the ages of 20 and 50 are more likely to get it.People who are treated for acute pericarditis may get it again. This may happen in 15 to 30 percent of people who have the condition. A small number of these people go on to develop chronic pericarditis.

CLINICAL FEATURES

Chest painRetrosternal chest painmore likely to be sharp and pleuritic with coughing, inspiration, swallowingworse by lying supine, relieved by sitting and leaning forwardCan often radiate to the neck, arms, or left shoulder.

Sudden in onset Pleuritic and sharp in nature Exacerbated by inspiration Mild feverDyspnea, orthopnea, tachycardiaPericardial friction rub Present in 85% of cases of pericarditis Pericardial friction rub is audible throughout the respiratory cycle, whereas the pleural rub disappears when respirations are on hold.

ECG (acute pericarditis)

EKG in Pericarditis

Widespread upward concave ST-segment elevation and PR-segment depression

If the ratio of ST-segment elevation to T-wave amplitude in V6 > 0.24, acute pericarditis is almost always present.

The EKG changes have 4 phases during the course of illness

Treatment

Bed rest as long as fever and pain persistTreatment of the underlying cause, if it can be

identifiedNonsteroidal anti-inflammatory drugs,

corticosteroidsAntibacterial, antifungal, or antiviral therapyNSAID (aspirin, indomethacin) are generally

accepted as effective for relieving symptoms of chest pain

NSAID ketorolac tromethamine rapid resultsColchicine may be a useful adjunct in those who

do not respond to NSAIDs alone

Complication

Pericardial effusionCardiac TamponadeConstrictive pericarditis

Prognosis

Pericarditis is usually a benign disorderDiagnosis relates to underlying causeBut any cause can lead to an effusion and

tamponade which can lead to deathPericarditis can also progress to pericardial

constriction and heart failure

Deferential diagnosis

MIAngina PectorisPulmonary Emboli

Pericarditis vs AMI

PericarditisPericarditis MIMI

ST segmentST segment Diffuse,concave elevation in all Diffuse,concave elevation in all leads except aVRleads except aVR++ V6 w/o V6 w/o reciprocal changesreciprocal changes

Height Not > 5mmHeight Not > 5mm

Localized, convex, with Localized, convex, with reciprocal changes in infarctreciprocal changes in infarct

Height may be > 5 mmHeight may be > 5 mm

PR depressionPR depression FrequentFrequent Almost neverAlmost never

Q wavesQ waves Not usual, unless with infarctNot usual, unless with infarct Common with q wave infarctCommon with q wave infarct

T wavesT waves Inverted after J returns to Inverted after J returns to baselinebaseline

T inversions and ST ↑ are not T inversions and ST ↑ are not seen simultaneously on the seen simultaneously on the same EKG same EKG

Inverted while ST still elevatedInverted while ST still elevated

T inversions and ST ↑ can be T inversions and ST ↑ can be seen simultaneously on the seen simultaneously on the same EKG same EKG

ArrhythmiasArrhythmias RareRare FrequentFrequent

Conduction Conduction disturbancesdisturbances

RareRare FrequentFrequent

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