A 32-year-old man comes to the emergency department with chest pain that started earlier in the day. The pain is midline and sharp and increases with deep breaths but decreases when the patient leans forward. He had a mild respiratory illness a week ago. Other medical history is unremarkable. The patient is a lifetime nonsmoker and has no family history of early-onset heart attack, sudden death, or cardiomyopathy. Blood pressure is 120/70 mm Hg and pulse is 110/min and regular. Which of the following physical examination findings is most expected in this patient?

Question

A 32-year-old man comes to the emergency department with chest pain that started earlier in the day.  The pain is midline and sharp and increases with deep breaths but decreases when the patient leans forward.  He had a mild respiratory illness a week ago.  Other medical history is unremarkable.  The patient is a lifetime nonsmoker and has no family history of early-onset heart attack, sudden death, or cardiomyopathy.  Blood pressure is 120/70 mm Hg and pulse is 110/min and regular.  Which of the following physical examination findings is most expected in this patient?

Quizplus · Accepted Answer

The chest pain of acute pericarditis is sharp and pleuritic and characteristically decreases when the patient sits and leans forward, which decreases pressure on the parietal pericardium. Fibrinous/serofibrinous pericarditis is the most common type of pericarditis, and a pericardial friction rub (described as high pitched, leathery, and scratchy) is the most specific physical finding. Fibrinous pericarditis may be caused by myocardial infarction, rheumatologic disease (eg, systemic lupus erythematosus), uremia, or viral infection. This patient's history of a recent upper respiratory illness suggests a viral etiology. (Choice B) During inspiration, jugular venous pressure normally decreases as blood is pulled into the right side of the heart. Kussmaul sign is a paradoxical increase in jugular venous pressure on inspiration. It occurs because of impaired right-sided diastolic filling in conditions such as constrictive pericarditis, restrictive cardiomyopathy, and tricuspid stenosis. Although constrictive (chronic) pericarditis can result from prolonged pericardial inflammation (over months to years), this patient's presentation is consistent with acute pericarditis, which is not associated with impaired right-sided diastolic filling. (Choice C) A pericardial knock is a brief, high-frequency, precordial sound heard in early diastole (shortly after S2) in patients with constrictive pericarditis. It occurs earlier than S3 and may be confused with the opening snap of mitral stenosis. (Choice D) Pulsus paradoxus is a drop in systolic blood pressure >10 mm Hg during inspiration. It represents an exaggeration of the normal reduction in systolic blood pressure during inspiration. It can be seen in cardiac tamponade, constrictive pericarditis, and severe asthma or chronic obstructive pulmonary disease. (Choice E) An S3 typically results from reverberation of the ventricular walls during rapid filling of an overfilled ventricle. It is usually associated with heart failure as occurs with dilated cardiomyopathy, severe mitral regurgitation, or severe aortic regurgitation. A right-sided S3 can occur with right-sided heart failure. Educational objective: Acute-onset, sharp, and pleuritic chest pain that decreases with leaning forward is characteristic of acute pericarditis. Fibrinous/serofibrinous pericarditis is the most common form of pericarditis and a pericardial friction rub is the most specific physical finding. Viral pericarditis is often preceded by an upper respiratory infection. __________ References: Acute pericarditis. (http://www.ncbi.nlm.nih.gov/pubmed/18052017)

A 32-Year-Old Man Comes to the Emergency Department with Chest