Cardiac Case: 19-year-old Man with Central Chest Pain Worsening when Breathing

00:00 A 19-year-old college student comes to the emergency department complaining of severe central - that is right here in the center of the chest -- chest pain for the last 2 days.

00:10 It worsens whenever she takes a deep breath or when she lies down.

00:15 Personal history: there's no previous cardiac history, she's a vigorous exerciser 4 times per week for the last 2 years with no symptoms during or after exercise.

00:26 Her laboratory test shows slightly elevated white blood count.

00:31 The normal white blood count is less than 10,000.

00:33 She's slightly elevated at 11,200 and she has 10% of her lymphocytes are atypical.

00:40 Atypical lymphocytes imply a viral infection and she has a slightly elevated blood troponin.

00:46 Troponin being one of the parts of the myocardial machinery, contractile machinery.

00:52 When the heart's injured, troponin is released into the blood stream.

00:56 It can happen with a heart attack; it can happen because there's a car accident where the heart is bruised, or from many other things that can damage the heart.

01:05 So, what's critical in this history first of all, persistent chest pain which is pleuritic.

01:12 It's worse when she takes a deep breath and worse when she lies down.

01:15 And the laboratory is suggesting an infective or an inflammatory process.

01:21 And here's her electrocardiogram.

01:24 Please look at it and see what you believe is abnormal about this cardiogram.

01:36 In fact, this cardiogram shows diffuse ST segment elevation. In Lead 1, there's ST elevation.

01:44 Lead 2, there's ST elevation. Lead 3, there's ST elevation.

01:47 And also, in AVF and then across the precordium there's ST elevation.

01:52 So almost all the leads have ST elevation and there's no reciprocal ST depression implying ischemia.

01:59 The diagnosis is pericarditis probably following a viral infection.

02:06 Acute viral pericarditis, she had little echo that showed a little bit of pericardial effusion.

02:12 Generally, the echo is done to make sure there's not a large pericardial effusion but it's quite common to have a small pericardial effusion with viral pericarditis.

02:22 Turns out, there were no major findings of too much fluid on the echo.

02:30 If there were a lot of fluid, it can sometimes compress the heart and decrease the blood pressure and we would have to drain the fluid.

02:36 And the treatment is non-steroidal anti-inflammatories such as indomethacin or ibuprofen and colchicine as well.

02:45 And generally, the patients do extremely well over the next week or two.

02:49 If we had seen a lot of fluid and there was evidence that the heart was tamponading, that is the fluid was squeezing the heart and decreasing cardiac output, this would require a trip to the cath lab to drain the fluid from the heart so that the heart function would improve.

03:04 That's pretty rare. Almost always we're able to handle this with the drugs.