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|QuestionAuthor={{M.P}}
|QuestionAuthor={{M.P}}
|ExamType=USMLE Step 3
|ExamType=USMLE Step 3
|MainCategory=Inpatient Facilities
|MainCategory=Emergency Room
|SubCategory=Electrolytes
|SubCategory=Cardiovascular
|MainCategory=Inpatient Facilities
|MainCategory=Emergency Room
|SubCategory=Electrolytes
|SubCategory=Cardiovascular
|MainCategory=Inpatient Facilities
|MainCategory=Emergency Room
|SubCategory=Electrolytes
|SubCategory=Cardiovascular
|MainCategory=Inpatient Facilities
|MainCategory=Emergency Room
|MainCategory=Inpatient Facilities
|MainCategory=Emergency Room
|SubCategory=Electrolytes
|SubCategory=Cardiovascular
|MainCategory=Inpatient Facilities
|MainCategory=Emergency Room
|SubCategory=Electrolytes
|SubCategory=Cardiovascular
|MainCategory=Inpatient Facilities
|MainCategory=Emergency Room
|SubCategory=Electrolytes
|SubCategory=Cardiovascular
|MainCategory=Inpatient Facilities
|MainCategory=Emergency Room
|SubCategory=Electrolytes
|SubCategory=Cardiovascular
|MainCategory=Inpatient Facilities
|MainCategory=Emergency Room
|MainCategory=Inpatient Facilities
|MainCategory=Emergency Room
|SubCategory=Electrolytes
|SubCategory=Cardiovascular
|Prompt=A 55 year old male who underwent gastric bypass surgery 2 days prior to carcinoma head of pancreas experiences generalized tonic clonic seizures.  Postoperatively, the patient was managed with opiods for pain at the surgical site and with IV fluids to hold blood pressure above 110/70 mmHg.  On examination the patient is lethargic and his vitals are temperature 37 degree Celsius, pulse: 106/min, blood pressure 120/70 mmHg and respirations: 16/min.  His pulse oximetry reading is 94 % in room air.  Electrolyte panel results are as follows:
|Prompt=A 35 year old male comes to the emergency department with sudden onset of chest pain for the past 3 hours.  The pain is retrosternal without any radiation to other areas and is exacerbated by inspiration.  He is not a smoker and does not consume alcohol.  His past history is insignificant and family history is unremarkable.  On examination, his vitals are temperature 38.2 degree Celsius, pulse: 106/min, blood pressure: 130/70 mmHg and respirations: 22/min.  His pulse oximetry reading is 94 % in room air.  Cardiovascular system examination reveals a high pitched, scratchy sound at the left sternal border with regular heart sounds.  Other system examinations are normal.  An urgent electrocardiogram done reveals diffuse ST segment elevation in leads V2 to V5 with reciprocal ST depression in leads aVR and V1.   What is the most appropriate next step in the management of this patient?
Serum Na: 112 mEq/L
|Explanation=[[Pericarditis]] is a condition in which the sac-like covering surrounding the [[heart]] (the [[pericardium]]) becomes inflamed.  Symptoms of [[pericarditis]] include [[chest pain]] which increases with deep breathing and lying flat.  Pericarditis is usually a complication of viral infections, most commonly [[echovirus]] or [[coxsackie virus]].  In addition, pericarditis can be associated with diseases such as autoimmune disorders, [[cancer]], [[hypothyroidism]], and [[kidney failure]].  Often the cause of pericarditis remains unknown, or [[idiopathic]].  A [[pericardial friction rub]] is the classic physical examination finding in pericarditis.  A careful examination must be performed to exclude the presence of [[cardiac tamponade]], characterized by the presence of [[pulsus paradoxus]], [[hypotension]], an elevated [[jugular venous pressure]], and [[peripheral edema]].  Patients with uncomplicated acute pericarditis can generally be treated and followed up in an outpatient clinic.  The treatment of viral or idiopathic pericarditis is with non-steroidal anti-inflammatory drugs.  The preferred [[NSAID]] is [[ibuprofen]] which has a large range of doses that can be titrated to the patient's tolerance.
Serum K: 4 mEq/L
|AnswerA=Oral ibuprofen
Chloride: 94 mEq/L
Bicarbonate: 24 mEq/L
BUN: 24 mg/dl
Serum creatinine: 1.2 mg/dl
Calcium: 9 mg/dl
Blood glucose: 130 mg/dl
What is the most appropriate next step in the management of this patient?
|Explanation=The electrolyte disturbance, [[hyponatremia]] is defined when sodium concentration in the plasma falls below 130 mmol/L.  [[Hyponatremia]] is due to an excess of free water in the body, not due to a deficiency of sodium.  The treatment of hyponatremia will depend on the underlying cause and whether the patient's volume status is hypervolemic, euvolemic, or hypovolemic.  In the setting of hypovolemia, intravenous administration of [[normal saline]] may be effective, but caution must be exercised not to raise the serum sodium level too quickly in order to lessen the chance of the development of [[central pontine myelinolysis]] (CPM), a severe neurological disease.  Euvolemic hyponatremia is usually managed by fluid restriction and treatment to abolish any stimuli for ADH secretion such as [[nausea]].  Likewise, drugs causing [[SIADH]] should be discontinued if possible.  Patients with euvolemic hyponatremia that persists despite those measures may be candidates for a so-called [[Hyponatremia medical therapy|vaptan drugs]].  Hypervolemic hyponatremia should be treated by treating the underlying cause (e.g. heart failure, cirrhosis).  In practice, it may not be possible to do so, in which case the treatment of the hyponatremia becomes the same as that for euvolemic hyponatremia (i.e. fluid restriction and/or use of a vaptan drug).  The rate of correction of [[hyponatremia]] should be 0.5-1.0meq/L/hr, with not more than a 12 meq/l correction in 24 hrs.  If the patient has ongoing seizures (or [Na+]<115 meq/L), correction can be attempted at up to 2 meq/L/hr, but only while [[seizure]] activity lasts and the [Na+] exceeds 125-130 meq/L.  
|AnswerA=Ringer lactate


|AnswerAExp=Ringer lactate is not used in the management of hyponatremia.
|AnswerB=3 % sodium chloride


|AnswerBExp=In patients with severe hyponatremic symptoms and in symptomatic patients with underlying intracranial disease, the serum sodium must initially be raised quickly to prevent possibly irreversible neurologic injury.  This patient has an ongoing seizures with plasma sodium concentration <115 meq/L, and hence correction can be attempted at up to 2 meq/L/hr using 3 % sodium chloride solution.  
|AnswerAExp=[[NSAIDs]] are the mainstay in the management of uncomplicated pericarditis.  The preferred [[NSAID]] is [[ibuprofen]] which has a large range of doses that can be titrated to the patient's tolerance.
|AnswerC=Water restriction
|AnswerB=High dose aspirin


|AnswerCExp=Patients with euvolemic [[hyponatremia]] and less severe symptoms of can be treated with less aggressive therapy, such as fluid restriction and oral salt tablets.
|AnswerBExp=An alternative therapy is [[aspirin]] 800 mg every 6-8 hours.  In symptomatic pericarditis occurring within days after an acute [[myocardial infarction]], aspirin is preferred.
|AnswerD=0.45 % normal saline
|AnswerC=Oral corticosteroids


|AnswerDExp=Hypervolemic hyponatremia should be treated by treating the underlying cause and intravenous administration of 0.45% normal saline can be used in rare cases.  
|AnswerCExp=[[Steroids]] are not used to treat an initial episode of [[pericarditis]]. They provide rapid relief in pain, but are associated with a high rate of recurrence.
|AnswerE=0.9 % normal saline
|AnswerD=Urgent cardiac catherization


|AnswerEExp=In the setting of hypovolemic hyponatremia, intravenous administration of 0.9% normal saline may be effective.  
|AnswerDExp=There is no evidence of myocardial ischemia or infarction in this patient.  Hence urgent cardiac catherization is not needed in this patient.
|EducationalObjectives=Serum sodium must initially be raised quickly to prevent irreversible neurologic injury in cases of severe symptomatic [[hyponatremia]].  
|AnswerE=Subcutaneous heparin
|RightAnswer=B
|AnswerEExp=Concomitant use of [[heparin]] and anticoagulant therapies is often perceived as a possible risk factor for the development of a worsening or hemorrhagic [[pericardial effusion]] that may result in [[cardiac tamponade]]. Hence heparin should be avoided whenever possible in these patients.  
|WBRKeyword=[[Hyponatremia]]
|EducationalObjectives=[[NSAIDs]] are the mainstay in the management of uncomplicated pericarditis.
|RightAnswer=A
|WBRKeyword=[[Pericarditis]]
|Approved=Yes
|Approved=Yes
}}
}}

Revision as of 22:17, 23 March 2014
Author [[PageAuthor::Mugilan Poongkunran M.B.B.S [1]]]
Exam Type ExamType::USMLE Step 3
Main Category MainCategory::Emergency Room
Sub Category SubCategory::Cardiovascular
Prompt [[Prompt::A 35 year old male comes to the emergency department with sudden onset of chest pain for the past 3 hours. The pain is retrosternal without any radiation to other areas and is exacerbated by inspiration. He is not a smoker and does not consume alcohol. His past history is insignificant and family history is unremarkable. On examination, his vitals are temperature 38.2 degree Celsius, pulse: 106/min, blood pressure: 130/70 mmHg and respirations: 22/min. His pulse oximetry reading is 94 % in room air. Cardiovascular system examination reveals a high pitched, scratchy sound at the left sternal border with regular heart sounds. Other system examinations are normal. An urgent electrocardiogram done reveals diffuse ST segment elevation in leads V2 to V5 with reciprocal ST depression in leads aVR and V1. What is the most appropriate next step in the management of this patient?]]
Answer A AnswerA::Oral ibuprofen
Answer A Explanation [[AnswerAExp::NSAIDs are the mainstay in the management of uncomplicated pericarditis. The preferred NSAID is ibuprofen which has a large range of doses that can be titrated to the patient's tolerance.]]
Answer B AnswerB::High dose aspirin
Answer B Explanation [[AnswerBExp::An alternative therapy is aspirin 800 mg every 6-8 hours. In symptomatic pericarditis occurring within days after an acute myocardial infarction, aspirin is preferred.]]
Answer C AnswerC::Oral corticosteroids
Answer C Explanation [[AnswerCExp::Steroids are not used to treat an initial episode of pericarditis. They provide rapid relief in pain, but are associated with a high rate of recurrence.]]
Answer D AnswerD::Urgent cardiac catherization
Answer D Explanation AnswerDExp::There is no evidence of myocardial ischemia or infarction in this patient. Hence urgent cardiac catherization is not needed in this patient.
Answer E AnswerE::Subcutaneous heparin
Answer E Explanation [[AnswerEExp::Concomitant use of heparin and anticoagulant therapies is often perceived as a possible risk factor for the development of a worsening or hemorrhagic pericardial effusion that may result in cardiac tamponade. Hence heparin should be avoided whenever possible in these patients.]]
Right Answer RightAnswer::A
Explanation [[Explanation::Pericarditis is a condition in which the sac-like covering surrounding the heart (the pericardium) becomes inflamed. Symptoms of pericarditis include chest pain which increases with deep breathing and lying flat. Pericarditis is usually a complication of viral infections, most commonly echovirus or coxsackie virus. In addition, pericarditis can be associated with diseases such as autoimmune disorders, cancer, hypothyroidism, and kidney failure. Often the cause of pericarditis remains unknown, or idiopathic. A pericardial friction rub is the classic physical examination finding in pericarditis. A careful examination must be performed to exclude the presence of cardiac tamponade, characterized by the presence of pulsus paradoxus, hypotension, an elevated jugular venous pressure, and peripheral edema. Patients with uncomplicated acute pericarditis can generally be treated and followed up in an outpatient clinic. The treatment of viral or idiopathic pericarditis is with non-steroidal anti-inflammatory drugs. The preferred NSAID is ibuprofen which has a large range of doses that can be titrated to the patient's tolerance.

Educational Objective: NSAIDs are the mainstay in the management of uncomplicated pericarditis.
References: ]]

Approved Approved::Yes
Keyword [[WBRKeyword::Pericarditis]]
Linked Question Linked::
Order in Linked Questions LinkedOrder::
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