Medical Mystery of the Week
You have received your COVID19 immunizations but continue to practice some Telemedicine.
You are shown a picture of the primary care physician listening to a patient who presented
with a chief complaint of chest pain. You are provided a recording of his auscultory
findings. You are given no other information.
What is your diagnosis, what test(s) do you advise to substantiate your suspicions,
and what treatment, if any, do you advise?
DIAGNOSIS: Pericarditis.
Pericarditis (PC) is the most common form of pericardial disease and a relatively
common cause of chest pain worldwide. Acute PC may mimick a myocardial infarction
in intensity and by radiating to the arm, shoulder, and/or neck. Because the phrenic
nerves and esophagus lie close to the posterior pericardium, symptoms may worsen with
deglutition and upon assuming a supine position; conversely, relief may occur with
the patient leaning forward.
The etiology of PC may be infectious or the result of systemic inflammatory
diseases, cancer, or post-cardiac injury syndromes. Tuberculosis is a major cause
of pericarditis in developing countries but accounts for less than 5% of cases in
developed countries where viruses (proven or probable) account for 80-90% of patients.
Nonsteroidal antiiflammatory agents (NSAIDs) comprise the most common treatment
for idiopathic and viral PC; adjuvant colchicine may ameliorate the initial episode
and is associated with ∼50% lower recurrent rates. Corticosteroids are a second-line
therapy for those that do not respond, are intolerant, or have contraindications to
NSAIDs and colchicine. Recurrences may occur in 30% of patients without preventitive
therapy.
Click here to listen to heart sounds (click back arrow to return to main content)
ANSWER TO BONUS QUESTION: Superior vena cava obstruction as evidenced by the downward (caudal) flow of blood in the neck vein
Video of these upper chest veins is best seen when enlarged.