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

by Joseph Alpert, MD

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    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.


    About the Lecture

    The lecture Cardiac Case: 19-year-old Man with Central Chest Pain Worsening when Breathing by Joseph Alpert, MD is from the course Cardiovascular Cases.


    Included Quiz Questions

    1. Infectious or inflammatory process
    2. Autoimmune disorder
    3. Myocardial infarction
    4. Cardiac tamponade
    5. Rhabdomyoma
    1. Outcomes for pericarditis are typically poor
    2. Troponin levels can increase any time there is damage to the cardiac tissue, even if it is secondary to trauma
    3. Cardiac tamponade would be treated with pericardiocentesis
    4. The typical treatment for uncomplicated pericarditis is an NSAID, such as indomethacin or colchicine
    5. Pericarditis is often secondary to a viral etiology

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

     Joseph Alpert, MD

    Joseph Alpert, MD


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