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| {{Family tree| | | | | | | A01 | | | | | A01= <div style="float: left; text-align: left; width:25em; padding:1em;">'''Characterize the symptoms:'''<br> | | {{Family tree| | | | | | | | | | A01 | | | | | A01= }} |
| ❑ [[Chest pain]]
| | {{Family tree| | | | | |,|-|-|-|-|^|-|-|-|-|.| }} |
| :❑ Sudden onset
| | {{Family tree| | | | | B01 | | | | | | | | B02 | B01= | B02= }} |
| :❑ Sharp or dull, aching and pressure like
| | {{Family tree| | | | | |!| | | | | | | | | | | | }} |
| :❑ Pleuritic (exacerbated by [[inspiration]] and [[coughing]])
| | {{Family tree| | | | | C01 | | | | | | | | C02 | C01= | C02= }} |
| :❑ Retrosternal
| | {{Family tree| |,|-|-|-|+|-|-|-|.| | | |,|-|^|-|.| | }} |
| :❑ Located in the [[trapezius]] muscle ridge
| | {{Family tree| D01 | | D02 | | D03 | | D04 | | D05 | D01= | D02= | D03= | D04= | D05= }} |
| :❑ Radiation to the neck or the arms
| | {{Family tree| |!| | | |!| | | |!| | | |!| | | |!| | }} |
| :❑ Affected by position (improved by sitting up and leaning forward)<br>
| | {{Family tree| E01 | | E02 | | E03 | | E04 | | E05 | E01= | E02= | E03= | E04= | E05= }} |
| :❑ No pain ([[uremia]] and [[tuberculosis]] pericarditis develop slowly)<br>
| | {{Family tree| | | | | | | | | | | | | | |!| |!| | | }} |
| '''Symptoms associated with pericardial effusion:'''<br>
| | {{Family tree| | | | | | | | | | | | | | | F01 | | | F01= }} |
| ❑ Without a hemodynamically significant pericardial effusion<br>
| | {{Family tree| | | | | | | | | | | | | |,|-|^|-|.| | }} |
| :❑ No specific symptoms
| | {{Family tree| | | | | | | | | | | | | G01 | | G02 | G01= | G02= }} |
| ❑ With a hemodynamically significant pericardial effusion<br>
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| :❑ [[Fatigue]]<br>
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| :❑ [[Breathlessness]]<br>
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| :❑ [[Orthopnea]] <br>
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| :❑ [[Dizziness]] <BR>
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| :❑ [[Hoarseness]] ([[recurrent laryngeal nerve]] compression) <br>
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| :❑ [[Hiccups]] ([[phrenic nerve]] compression) <BR>
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| :❑ [[Abdominal pain]] ([[mesenteric ischemia]]) <BR>
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| :❑ [[Nausea]] ([[diaphragm]] irritation) <BR>
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| :❑ [[Loss of consciousness]]<br>
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| :❑ [[Cool extremities]]<br>
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| :❑ [[Peripheral cyanosis]] <br>
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| :❑ [[Peripheral edema]] <br>
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| '''Other etiology associated symptoms:'''<br>
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| ❑ [[Fever]] (suggestive of infectious etiology)<br>
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| ❑ [[Cough]] (suggestive of infectious etiology)<br>
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| ❑ [[Palpitations]] <br>
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| ❑ [[Malaise]] <br>
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| ❑ [[Joint pains]] (suggestive of autoimmune etiology)<br>
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| ❑ [[Odynophagia]] <br>
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| ❑ [[Weight loss]] (suggestive of malignant etiology) </div>}}
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| {{Family tree| | | | | | | |!| | | | | | }} | |
| {{Family tree| | | | | | | B01 | | | | | B01= <div style="float: left; text-align: left; width:25em; padding:1em;">'''Obtain a detailed history:'''<br> | |
| ❑ Infections
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| :❑ [[Pneumonia]]
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| :❑ [[Tuberculosis]]
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| :❑ [[HIV]]
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| :❑ Travel history
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| ::❑ Travel to Central or South America ([[Chagas disease]])
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| ::❑ Travel to Central Asia or South Africa or South America ([[Tuberculosis]])<ref name="pmid23968879">{{cite journal| author=| title=WHO launches World health report 2013. | journal=Euro Surveill | year= 2013 | volume= 18 | issue= 33 | pages= 20559 | pmid=23968879 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23968879 }} </ref>
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| ::❑ Travel to North and Central America, such as Ohio and Mississippi River valleys ([[Histoplasmosis]])
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| ::❑ Travel to North America ([[Blastomycosis]]) <br>
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| ❑ [[Pericarditis causes#Causes by Organ System|Medications]]
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| :❑ [[5-Fluorouracil]]
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| :❑ [[Amiodarone]]
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| :❑ [[Anticoagulants]]
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| :❑ [[Cyclosporine]]
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| :❑ [[Cyclophosphamide]]
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| :❑ [[Cytarabine]]
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| :❑ [[Daunorubicin]]
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| :❑ [[Doxorubicin]]
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| :❑ [[Drug-induced lupus erythematosus causes|Drug-induced lupus erythematosus]]
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| :❑ [[Methysergide]]
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| :❑ [[Penicillins]]
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| :❑ [[Sulfa drugs]]
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| :❑ [[Thiazides]]
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| :❑ [[thrombolysis|Thrombolytic agents]]
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| ❑ Systemic illness
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| :❑ [[Collagen vascular disease]]
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| :❑ [[Hypothyroidism]]
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| :❑ [[Inflammatory bowel disease]]
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| :❑ [[Malignancy]]
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| :❑ [[Uremia]]<br>
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| ❑ Others
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| :❑ [[Cardiac surgery]]
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| :❑ [[Radiation exposure]]
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| :❑ [[Dressler's syndrome]]
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| :❑ [[Postpericardiotomy syndrome]]
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| :❑ [[chest trauma|Trauma history]] </div>}}
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| {{Family tree| | | | | | | |!| | | | | | }} | |
| {{Family tree| | | | | | | C01 | | | | | C01= <div style="float: left; text-align: left; width:25em; padding:1em;">'''Examine the patient:'''<br>
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| '''Vital signs''' <br>
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| ❑ [[Pulse]]
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| :❑ [[Tachycardia]] (typical)
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| :❑ [[Bradycardia]] (in [[hypothyroidism]] and [[uremia]])
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| :❑ [[Pulsus paradoxus]] (in [[cardiac tamponade]])
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| ❑ [[Blood pressure]]
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| :❑ Normal (typical)
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| :❑ [[Hypotension]] (in [[cardiac tamponade]])
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| ❑ [[Temperature]]
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| :❑ [[Fever]] less than 39°C or 102.2°F
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| :❑ [[Hypothermic]] (in elderly and [[renal failure]])
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| ❑ [[Respiratory rate]]
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| :❑ [[Tachypnea]] (typical)
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| '''Cardiovascular system''' <br>
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| '''Auscultation''' <br>
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| ❑ Heart sounds
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| :❑ Normal (typical)
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| :❑ New [[S3]] heart sound
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| :❑ Distant and muffled (in [[cardiac tamponade]])
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| ❑ [[Murmur]] (in concomitant heart disease)<br>
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| ❑ [[Pericardial friction rub]]
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| :❑ High pitched, scratchy or squeaky sound
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| :❑ Best heard at the left sternal border
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| :❑ Best heard with the diaphragm of the stethoscope
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| :❑ Varies in intensity overtime and needs repeated examinations
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| <center>{{#ev:youtube|watch?v=EUCp_3_vwtw|300}}</center>
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| '''Palpation''' <br>
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| ❑ [[Jugular venous pulse]]
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| :❑ Elevated (in [[cardiac tamponade]] and [[constrictive pericarditis]]) <br>
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| :❑ [[Kussmaul sign]] (in [[constrictive pericarditis]]) <br>
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| '''Percussion''' <br>
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| ❑ Cardiac dullness beyond the apical point of maximal impulse (in [[pericardial effusion]]) <br>
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| '''Respiratory system''' <br>
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| ❑ [[Wheeze]] or [[rales]]<br>
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| ❑ [[Pleural effusion]]<br>
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| '''Abdomen'''
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| ❑ Pulsatile [[hepatomegaly]] (in [[constrictive pericarditis]]) <br>
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| ❑ [[Ascites]] </div>}}
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| {{Family tree| | | | | | | |!| | | | | | }} | |
| {{Family tree| | | | | | | D01 | | | | | D01= <div style="float: left; text-align: left; width:25em; padding:1em;">'''Order tests (Urgent):''' <br><br> | |
| '''Order laboratory tests (urgent):'''<br>
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| ❑ [[Complete blood count|CBC]] ([[leucocytosis]]) <br>
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| ❑ [[ESR]] (elevated) <BR>
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| ❑ [[C reactive protein]] (elevated) <br>
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| ❑ [[troponin|Serum cardiac troponin I and T]] <br>
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| ❑ [[Creatine kinase]] (CK-MB) <br>
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| ❑ [[myoglobin|Serum myoglobin]] <br>
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| ❑ [[tumour necrosis factor|Serum tumour necrosis factor]] <br>
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| ❑ [[urea|Serum urea]] and [[creatinine]] <br>
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| ----
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| '''Order [[electrocardiogram]] (urgent):'''<br>
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| ❑ [[Pericarditis electrocardiogram|Typical findings in pericarditis]]
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| :❑ [[ST segment elevation]] in leads I, II, aVL, aVF, and V3-V6
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| :❑ [[PR segment depression]]
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| :❑ [[ Low QRS voltage]] (in large [[pericardial effusion]] and [[constrictive pericarditis]])
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| [[Image:Acute-pericarditis.jpg|center|200px|thumb|ST elevation in leads I, II, V2, V3, V4, V5, and V6 depicting acute pericarditis]]
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| ❑ [[Electrical alternans]] (in [[cardiac tamponade]])<br>
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| ----
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| '''Order imaging (urgent):'''<br>
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| ❑ [[Chest X-ray]] <br>
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| :❑ Clear lung fields (typical)
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| :❑ A flask-shaped, enlarged cardiac silhouette (in [[pericardial effusion]] and [[cardiac tamponade]])
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| :❑ Lateral view may reveal
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| ::❑ Thickened pericardial line (in [[pericarditis]], [[pericardial effusion]])
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| ::❑ Irregular contours of cardiac silhouette (in [[pericarditis|chronic pericarditis]], [[pericardial fibrosis]], post surgery, [[metastasis]])
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| [[Image:Pericardial effusion_3.jpg|thumb|150px|left|Pericardial effusion]]
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| <br clear="left"/>
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| ❑ [[Echocardiography]] (diagnostic test of choice)<br>
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| :❑ [[Pericarditis echocardiography|Typical findings in pericarditis]]
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| ::❑ Presence of moderate and large [[pericardial effusion]]
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| ::❑ Right atrial collapse
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| ::❑ Diastolic collapse of [[right ventricle]] and [[left atrium]] (specific for cardiac tamponade)
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| :❑ Check for concomitant [[heart disease]] or paracardial pathology </div>}}
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| {{Family tree| | | | | | | |!| | | | | | }}
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| {{Family tree| | | | | | | E01 | | | | | E01= <div style="float: left; text-align: left; width:25em; padding:1em;">'''Does the patient have at least two of the following criteria for the diagnosis of acute pericarditis?'''<br> | |
| ❑ Characteristic [[chest pain]] <br>
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| :❑ Sharp and pleuritic that is improved by sitting up and leaning forward
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| ❑ [[Pericardial friction rub]] <BR>
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| :❑ High pitched, scratchy sound at the left sternal border best heard with the diaphragm of the stethoscope
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| :❑ Heard during [[atrial systole]], [[ventricular systole]] and rapid ventricular filling in early [[diastole]]
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| ❑ Suggestive [[ECG]] changes <br>
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| :❑ Diffuse [[ST elevation]] with reciprocal [[ST depression]] in leads aVR and V1
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| ❑ Suggestive [[echocardiography]] changes <br>
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| :❑ New or worsening [[pericardial effusion]] </div>}}
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| {{Family tree| | | |,|-|-|-|^|-|-|-|.| | }}
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| {{Family tree| | | F01 | | | | | | F02 | F01= Yes| F02= No}} | |
| {{Family tree| | | |!| | | | | | | |!| | }}
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| {{Family tree| | | G01 | | | | | | G02 | | G01= <div style="float: left; text-align: left; width:15em; padding:1em;">'''Does the patient have any sign of myocarditis?'''<br> | |
| ❑ Elevated [[cardiac enzymes]], or <BR>❑ Global or regional myocardial dysfunction on echocardiography </div>| G02= <div style="float: left; text-align: left; width:15em; padding:1em;">'''Does the patient have any signs suspicious of acute pericarditis?'''<br>
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| ❑ Ongoing [[fever]] <BR>
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| ❑ Poor response to treatment<br>
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| ❑ Hemodynamic compromise </div>}}
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| {{Family tree| |,|-|^|-|.| | | |,|-|^|-|.| | }} | |
| {{Family tree| H01 | | H02 | | H03 | | H04 | H01= No| H02= Yes| H03= No| H04= Yes}}
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| {{Family tree| |!| | | |!| | | |!| | | |!| | }} | |
| {{Family tree| I01 | | I02 | | I03 | | I04 | I01= Acute pericarditis| I02= Myopericarditis| I03= <div style="float: left; text-align: left; width:15em; padding:1em;">Consider alternative diagnosis and treat accordingly </div>| I04= Consider cardiac MRI (CMR)<ref name="pmid20511488">{{cite journal |author=Khandaker MH, Espinosa RE, Nishimura RA, ''et al.'' |title=Pericardial disease: diagnosis and management |journal=Mayo Clinic Proceedings. Mayo Clinic |volume=85 |issue=6 |pages=572–93 |year=2010 |month=June |pmid=20511488 |pmc=2878263 |doi=10.4065/mcp.2010.0046 |url=}}</ref>}} | |
| {{Family tree| | | | | | | | | | | | | |!| | }} | |
| {{Family tree| | | | | | | | | | | | | J01 | J01= <div style="float: left; text-align: left; width:15em; padding:1em;">Treat as acute pericarditis or myopericarditis if there is delayed enhancement on CMR </div>}}
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| {{Family tree/end}} | | {{Family tree/end}} |