N512-19A Module Two: Cardiovascular Disease Across the Life Span

The pericardium is the protective coating of the heart, and when the pericardium becomes inflamed, the condition is referred to as pericarditis, and can be acute or chronic (Berkowitz, 2020).   J.J’s primary complaint is severe retrosternal chest pain that radiates to the back, worse with taking a deep breath, and improved with leaning forward, and these key symptoms are indicative of pericarditis (Hammer and McPhee, 2019).    According to Hammer & McPhee (2019) another key indicator for pericarditis is the pericardial friction rub, which results from friction between the visceral and parietal pericardial surfaces, and presents as a three component high pitched squeaking sound on exam. The three components heard result from the increased movement of the heart chambers (Hammer & McPhee, 2019). 

The most common symptom for pericarditis is chest pain, however there can be many other causes for chest pain, so another possible differential diagnosis for chest pain such as myocardial infarction, must be ruled out (Up to Date, 2020).  The key feature for acute pericarditis is sudden sharp, pleuritic chest pain in the front of the chest, that gets worse with coughing, and pain typically gets better with positional changes like leaning forward (Up To Date, 2020).  In order to rule out other causes for chest pain, an echocardiogram should be used for evaluation of determining the cause of chest pain.  The ECG changes differ in pericarditis versus changes seen with myocardial infarction (Up to Date, 2020).

According to Hammer and McPhee (2019), pericarditis is most commonly caused by viral infections, specifically the coxsackievirus.  Other less common causative agents include protoza, fungi, and bacteria. In addition, any damage or injury to the heart such as with chest trauma or myocardial infarction can lead to pericarditis as well (Hammer and McPhee).  In the case of J.J., she presents with viral “flu like illness,” is young, and has no other underlying medical condition, so her pericarditis is most likely due to coxsackievirus infection (Hammer & McPhee, 2019). 

The pathophysiologic mechanism for the chest pain is due to the inflammation of the pericardial lining of the heart and surrounding pleuritic cells, which causes the feature of increasing pain with coughing and deep breathing (Hammer & McPhee, 2019).  According to Hammer & McPhee (2019)  with acute inflammation of the pericardium, vascularity increases, increase in polymorphonuclear leukocytes, and fibrin deposits. This acute inflammation ultimately causes the rubbing together of pericardial surfaces that manifest with chest pain.  In chronic pericarditis, the pericardium forms calcium deposits, and becomes scarred and fibrotic, resulting in constrictive pericarditis (Hammer& McPhee, 2019).  

As a nurse practitioner I would advise J.J. to continue with medications used to decrease the inflammation and manage her pain associated with it (Wolters klewer, 2020).  Common NSAIDS such as Ibuprofen and Advil, are commonly used to treat the inflammation, along with Colchicine to reduce inflammation if appropriate for the patient (Mayo Clinic, 2018).  According to Mayo Clinic (2018) when anti-inflammatory drugs are  ineffective for reducing inflammation, corticosteroids are prescribed for reducing inflammation.

It is  important for J.J. to get adequate amounts of rest, and eat a balanced diet, which are important for recovery.  I would also advise J.J. to avoid any strenuous exercise which can exacerbate the symptoms of pericarditis (Mayo Clinic, 2018).  In addition she should reach out to her family to assist in making her comfortable, such as help with daily activities at home, and this will ensure that she is getting adequate amounts of rest at home for recovery.   Lastly it is important for J.J. to monitor her symptoms, and to come in for reevaluation for worsening symptoms such as fever onset or increasing shortness of breath,  that can ultimately lead to pericardial effusion and pericardial tamponade (Hammer & McPhee, 2019). 

References 

Berkowitz, A. (2019) Clinical Pathophysiology Made Ridiculously Simple. Copyright 2007 by Medmaster Inc

Hammer, G., & McPhee, S. (2019). Pathophysiology of disease: An introduction to clinical     medicine (8th ed). McGraw-Hill.

Mayo Clinic. (2018, March). Pericarditis. mayoclinic.org. https://www.mayoclinic.org/diseases-conditions/pericarditis/diagnosis-treatment/drc-20352514

Rebar, C., Heimgartner, M., & Gersch, C. (2018) Pathophysiology Made Incredibly Easy. 6th Edition. Philadelphia. Wolters Kluwer.

Up To Date. (May, 2020). Acute pericarditis: Clinical presentation, diagnostic evaluation, and diagnosis. Up to Date. N512-19A Module Two: Cardiovascular Disease Across the Life Span

https://www.uptodate.com/contents/acute-pericarditis-clinical-presentation-diagnostic-evaluation-and-diagnosis