WBR0014

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Author [[PageAuthor::Raviteja Reddy Guddeti MBBS, Aarti Narayan MBBS, Ayokunle Olubaniyi, M.B,B.S [1]]]
Exam Type USMLE Step 2 CK
Main Category Internal medicine
Sub Category Cardiovascular
Prompt 30-year-old male presents to the emergency room with complaints of low-grade fever associated with severe retrosternal chest pain that is referred to the back and the left lower part of the scapula. Upon further inquiry the patient states that the pain is aggravated by lying supine and relieved by sitting and leaning forward.

What is the most appropriate diagnosis?

Answer A Angina
Answer A Explanation The chest pain of angina is of sudden onset, often described as "squeezing", with a dull heavy pressure, and sometimes with radiation to left jaw, neck and arm and lasts for 2-10 minutes.
Answer B Myocardial infarction
Answer B Explanation [[AnswerBExp::The chest pain of a myocardial infarction is similar to that of angina, but severe and usually lasts for more than 20 minutes.]]
Answer C Costochondritis
Answer C Explanation [[AnswerCExp::The pain of costochondritis is associated with tenderness around the breast bone, and aggravated by coughing, deep inspiration and sneezing.]]
Answer D Acute pericarditis
Answer D Explanation Acute pericarditis is the correct answer, with retrosternal pain radiating to the back and the left trapezius ridge.
Answer E Pleuritis
Answer E Explanation [[AnswerEExp::The pain of pleuritis is sharp, localized, and is aggravated by deep inspiration and coughing. It is often associated with signs and symptoms of a respiratory infection.]]
Right Answer D
Explanation [[Explanation::The correct answer is acute pericarditis. Pericarditis refers to the inflammation of the fibroelastic sac surrounding the heart (pericardium). It can be dry, fibrinous or effusive independently from the etiology. Depending on the time of presentation and duration, pericarditis is divided into:
  • Acute (<6 weeks)
  • Subacute (6 weeks to 6 months)
  • Chronic (>6 months)

The clinical suspicion of acute pericarditis is based on a history of the characteristic pleuritic chest pain -- which is sharp, constricting, aggravates on inspiration and on lying supine, and relieved by sitting up and leaning forward. A pericardial friction rub may also be auscultated during cardiac examination.

NSAIDs are the mainstay in the treatment of acute pericarditis and ibuprofen is the most preferred drug.
Educational Objective: A characteristic finding of a sharp and constricting pleuritic chest pain, which is aggravated on inspiration and on lying supine, and relieved by sitting up and leaning forward, raises the clinical suspicion of acute pericarditis. A pericardial friction rub may also be auscultated during cardiac examination. NSAIDs are the mainstay of therapy.
References: Braunwald E. Pericardial disease. In: Kasper DL, Braunwald E, Fauci AS, et al, eds. Harrison's internal medicine. 16th ed. New York: McGraw-Hill; 2005.]]

Approved Yes
Keyword Pericarditis
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