A 71-year-old man is brought to the emergency room due to sharp chest pain for 2 hours. The pain is not related to exertion but is worse with deep breaths. He has not done any unusual activity lately. The patient has a history of advanced chronic kidney disease and is preparing to initiate chronic dialysis soon. His other medical problems include type 2 diabetes mellitus, hypertension, and lumbar spinal stenosis. The patient does not use tobacco or illicit drugs but consumes 1 alcoholic drink with dinner on most nights. Temperature is 37.7 C (99.8 F), blood pressure is 160/98 mm Hg in both arms, pulse is 98/min, and respirations are 20/min. When the patient is placed in a supine position during the examination, he experiences chest pain that appears to improve when he sits back up. A diastolic sound with a squeaking quality is heard at the left sternal border. Breath sounds are normal. ECG shows nonspecific T wave abnormalities. Chest x-ray is normal. Cardiac enzymes are normal. Laboratory studies show a blood urea nitrogen level of 68 mg/dL and a serum creatinine of 5.3 mg/dL. Which of the following is the most likely diagnosis?

Question

A 71-year-old man is brought to the emergency room due to sharp chest pain for 2 hours.  The pain is not related to exertion but is worse with deep breaths.  He has not done any unusual activity lately.  The patient has a history of advanced chronic kidney disease and is preparing to initiate chronic dialysis soon.  His other medical problems include type 2 diabetes mellitus, hypertension, and lumbar spinal stenosis.  The patient does not use tobacco or illicit drugs but consumes 1 alcoholic drink with dinner on most nights.  Temperature is 37.7 C (99.8 F), blood pressure is 160/98 mm Hg in both arms, pulse is 98/min, and respirations are 20/min.  When the patient is placed in a supine position during the examination, he experiences chest pain that appears to improve when he sits back up.  A diastolic sound with a squeaking quality is heard at the left sternal border.  Breath sounds are normal.  ECG shows nonspecific T wave abnormalities.  Chest x-ray is normal.  Cardiac enzymes are normal.  Laboratory studies show a blood urea nitrogen level of 68 mg/dL and a serum creatinine of 5.3 mg/dL.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d171_4152_bc81_ff6122be3236_MD0003_00 This patient likely has acute uremic pericarditis. The pathogenesis is poorly understood, but, essentially, elevated levels of blood urea nitrogen >60 mg/dL can lead to inflammation of the visceral and parietal layers of the pericardium. Patients may have acute or chronic renal failure and typically present with pleuritic chest pain (often radiating to the back) that is worse in the supine position and improves with sitting up. Cardiac auscultation typically reveals a pericardial friction rub (high-frequency grating or squeaking sound) best heard at the left sternal border with the patient leaning forward. The rub may occur during systole, diastole, or both. Unlike other etiologies of pericarditis, uremic pericarditis does not typically cause diffuse ST elevation (or PR depression) on ECG as the inflammation does not affect the myocardium. Initiation of dialysis is indicated for uremic pericarditis (symptomatic uremia) and typically leads to resolution of symptoms. However, as >50% of cases are accompanied by pericardial effusion, cardiac tamponade should be ruled out prior to dialysis initiation. (Choice A) Aortic dissection typically presents with sudden-onset tearing chest pain radiating to the back in a patient with uncontrolled hypertension. Chest pain that worsens with breathing and supine position is not typical. (Choice B) Gastroesophageal reflux disease typically presents with nonpleuritic, burning chest pain and sensation of reflux that may improve with sitting up. However, a pericardial friction rub should not be present. (Choices C and F) Acute coronary syndrome due to unstable angina or myocardial infarction typically presents with nonpleuritic chest pain accompanied by nausea, dyspnea, fatigue, or diaphoresis. Pleuritic chest pain that changes in intensity with position is not typical. (Choice E) Pulmonary embolism can present with sudden onset of dyspnea and pleuritic chest pain. However, positional changes in pain intensity and a pericardial friction rub are not typical. (Choice G) Viral pleurisy is an inflammation of the lung pleura that typically presents with fever and pleuritic chest pain. A pleural friction rub may be present and is differentiated from a pericardial friction rub by disappearance during breath holding. Renal failure makes uremic pericarditis more likely. Educational objective: Uremic pericarditis results from inflammation of the visceral and parietal layers of the pericardium. Patients have advanced renal failure (blood urea nitrogen >60 mg/dL) and typically present with pleuritic chest pain and a pericardial friction rub. The classic ECG finding of diffuse ST elevation is typically absent due to lack of myocardial inflammation. References: Pericardial disease in renal patients. (http://www.ncbi.nlm.nih.gov/pubmed/11172559)

A 71-Year-Old Man Is Brought to the Emergency Room Due