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.