By :SITI NURUL AINC111 08 784

Supervisor :Dr. MUZAKKIR AMIR,Sp.JP,FIHA,FICA

Patient IdentityName : Mr. YKAge : 41 years oldAddress : Takallar PattalasangMedical record : 536023Admitted : January 1st 2013

History Taking

Chief complaint: Chest pain

History taking: Experienced since 2 days ago before he was admitted to the hospital, constant retrosternal sharp pain and aggravated by inspiration. The pain becomes worse when he lies down and improves when he sits up and leans forward. Shortness of breath (-), sweating(+), nausea(+), vomitting (+) freq 3x. PND (-), DOE (-)Fever (+), since 2 days before admitted to the hospital, Headache (-)Epigastric pain (-), Cough (-)History of previous chest pain (-)Defecation & micturation: Normal

PAST ILLNESS HISTORY

History of Hypertension (-)History of DM (-)Family history of heart disease (-)History of smoking (+) : Since 10 years ago, 1-2 packs dailyHistory of Post-Op urolithiasis on December 2012

Physical ExaminationGeneral State : Moderate-illness/normal Body Weight/composmentisVital Sign :Blood Pressure: 110/70 mmHgPulse : 88 bpm, regularRespiratory rate : 20 tpm, abdominothoracalBody temperature : 36.8 C (per axilla)

Head ExaminationEyes: anemic -/-, icterus -/-Lip : cyanosis (-)Neck: lymphadenopathy (-), JVP R +0 cmH2O

Thoraxic ExaminationInspection : symmetric R=L, normochestPalpation : mass (-), tenderness (-), VF R=LPercussion : sonorAuscultation: breath sound: vesicular additional sound : ronchi - /- wheezing -/-

Cardiac Examination

Inspection : Ictus cordis not visiblePalpation : Ictus cordis not palpable Percussion :

Upper border : left 2nd ICSLower border : left 6th ICS Right border : Right parasternalis lineLeft border : 2 cm from Left midclavicular line

Auscultation: Heart sound I/II regular, murmur (-)

Abdominal Examination

- Inspection: flat & following breath movement- Auscultation : peristaltic sound (+) , normal - Palpation : liver and spleen unpalpable- Percussion : tympani, ascites (-)

Extremities

Oedema : pretibial -/-

: dorsum pedis -/-

ECG

InterpretationRhythm: Sinus rythmHeart Rate : 85 x/minuteP wave: 0,08PR Interval: 0,12 msQRS Complex: 0,08Axis: NormoaxisST Segment: - II, III, aVF = ST Elevation Inferior - V2 = ST Elevation Septal - V3+V4 = ST Elevation Anterior - V5+V6 = ST Elevation LateralConclusion: Sinus rhythm, HR 85x/minute, normoaxis, diffuse ST -elevation ,PR depression.

Echocardiography

Conclusion LV & RV Systolic function good,EF 59%Global normokineticLVH ( +)Diastolic dysfunctionMild pericardial effusion

LABORATORY FINDINGS(01/01/2013)

Routine Blood Test

RBC: 4.40 x106/mm3WBC: 24.1 x103/mm3HB: 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/LT.cholesterol: 96 mg/dlHDL : 6 mg/dlLDL : 32mg/dlTG : 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 DIAGNOSISSUSP.ACUTE PERICARDITIS

FINAL DIAGNOSIS

ACUTE PERICARDITIS

MANAGEMENT

O2 2 L/minIVFD NaCl 0.9% 500cc/24h/ivAntibioticCeftriaxone 2 gr/24h/ivNSAIDSIbuprofen 400 mg 3x1anti-anginal(trimetazidinehydrochloride)Trizedon MR 2x1

Pericarditis

DEFINITIONPericarditis inflammation (swelling) of the pericardium. A characteristicchest painis often present.acute and chronic form.more common in adults (typically between 20 to 50 years old) and in men.

Anatomy and physiologyPericardial Layers: Visceral layer Parietal layer Fibrous pericardium

Function of the Pericardium1. Stabilization of the heart within the thoracic cavity by virtue of its ligamentous attachments -- limiting the hearts motion.

2. Protection of the heart from mechanical trauma and infection from adjoining structures.

3. The pericardial fluid functions as a lubricant and decreases friction of cardiac surface during systole and diastole.

4. Prevention of excessive dilation of heart especially during sudden rise in intra-cardiac volume (e.g. acute aortic or mitral regurgitation).

Pathogenesis

Etiologies of PericarditisI. INFECTIVEII. AUTOIMMUNE DISORDERSIII. NEOPLASMIV. RADIATION PERICARDITISV. RENAL FAILURE (uremia)VI. TRAUMATIC CARDIAC INJURY

Clinical ManifestationAcute pericarditis: Chest pain: -sudden and severe pain/sharp pain -radiating -worsen when breathing/lying flat -relieved by sitting up/leaning forwardfeverPericardial effusion: breathing difficulty or ill-defined pain or fullness in the chest.Chronic pericarditis: swelling in the legs and abdomen due to fluid retention, breathing difficulty, fatigue.

Pericardial Friction RubAuscultationScratchy or squeaky sound Use the diaphragmsuspended respirationHighly specific for pericarditis (up to 85%). Intermittent sensitivity can vary.Heard better in patients without effusion. Result of friction from 2 inflamed layers of pericardium

ECG (acute pericarditis)diffuse, non-specific, concave, ST segment-elevations all leads except aVR and V1 PR segment-depression possible in any lead except aVRsinus tachycardia, and low-voltage QRS complexes can also be seen if there is subsymptomatic levels of pericardial effusion.

Treatment*Bed rest *Treatment of the underlying cause*Non-steroidal Anti-inflammatory Drugs (NSAIDs):-reducepain andinflammation-ibuprofen:300-800 mg every 6-8 hours/ days / weeks*Aspirin Therapy:-aspirin80 mg every 6-8 hours*Colchicine*Steroids

Complications

Pericardial effusionCardiac TamponadeConstrictive pericarditis

PrognosisPericarditis 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 diagnosisMIPulmonary Embolism

Pericarditis vs MI

Characteristic/Parameter Acute PericarditisMyocardial infarctionPain descriptionSharp,pleuritic retro-sternal (under the sternum) or left precordial (left chest) painCrushing, pressure-like, heavy pain. Described as "elephant on the chest."RadiationPain radiates to the trapezius ridge (to the lowest portion of the scapula on the back) or no radiation.Pain radiates to the jaw, or the left or arm, or does not radiate.ExertionDoes not change the painCan increase the painPositionPain is worse in thesupine positionor upon inspiration (breathing in)Not positionalOnset/durationSudden pain, that lasts for hours or sometimes days before a patient comes to the ERSudden or chronically worsening pain that can come and go inparoxysmsor it can last for hours before the patient decides to come to the ER

Comparison of ECG Changes Associated with Acute Pericarditis, Myocardial Infarction and Early Repolarization

ECG findingAcute pericarditisMyocardial infarctionEarly repolarizationST-segment shapeConcave upwardConvex upwardConcave upwardQ wavesAbsentPresentAbsentReciprocal ST-segment changesAbsentPresentAbsentLocation of ST-segment elevationLimb and precordial leadsArea of involved arteryPrecordial leadsST/T ratio in lead V6*>0.25N/A

THANK YOU

****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.

*I. INFECTIVE1. VIRAL - Coxsackie A and B, Influenza, adenovirus, HIV, etc. 2. BACTERIAL - Staphylococcus, pneumococcus, tuberculosis, etc.3. FUNGAL - Candida4. PARASITIC - Amoeba, candida, etc.II. AUTOIMMUNE DISORDERS1. Systemic lupus erythematosus (SLE)2. Drug-Induced lupus (e.g. Hydralazine, Procainamide)3. Rheumatoid Arthritis4. Post Cardiac Injury Syndromes i.e. postmyocardial Infarction (Dressler's) Syndrome, postcardiotomy syndrome, etc.III. NEOPLASM1. Primary mesothelioma2. Secondary, metastatic3. Direct extension from adjoining tumorIV. RADIATION PERICARDITISV. RENAL FAILURE (uremia)VI. TRAUMATIC CARDIAC INJURY1. Penetrating - stab wound, bullet wound2. Blunt non-penetrating - automobile steering wheel accidentVII. IDIOPATHIC

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