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Cases
Chest Pain for 2 Days
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Background
A
38-year-old man without cardiac risk factors presents with chest
pain that has been continuous for 2 days. His vital signs are as
follows: temperature, 99°F; heart rate, 86 beats per minute;
blood pressure, 140/78 mm Hg; and respiratory rate, 21 per
minute.
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Scroll
down for Hint and Answer
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***** HINT *****
The patient looks comfortable despite changes on his ECG. He had symptoms of a
common cold 3 weeks ago.
***** ANSWER *****
The ECG shows a normal
sinus rhythm (NSR) that is regular, with normal intervals. ST elevation is
notable in leads II, III, aVF, and V3 through V6. Note that the PR depression is
most visible in leads II and V2 through V6. Corresponding PR elevation is noted
in the aVR lead. The ECG findings are consistent with acute pericarditis, which
can cause friction rub to be heard on examination. In stage I (as shown here),
diffuse ST elevation is present in leads I, II, aVL, aVF, and V3 through V6, and
reciprocal ST depressions are seen in leads aVR and V1. Inflammation cannot
occur superficial to the thin-walled atria; therefore, some myocarditis occurs.
Exaggerated atrial T waves cause PR-segment depressions with a polarity opposite
to that of the P wave. PR elevation, as shown in the aVR lead, is a reliable
indicator of pericarditis. In stage II, the ST elevations and PR depressions
resolve, and the ECG normalizes. In stage III, generalized T-wave inversions are
present in most or all leads. In stage IV, the ECG returns to its state before
the pericarditis, or the T-wave inversions become permanent. Reference:
Braunwald E, Zipes DP, Libby P. Braunwald’s Heart Disease: A Textbook of
Cardiovascular Medicine. 6th ed. Philadelphia, Pa: WB Saunders Company;
2001:1827-9.
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Contributed by:
Basmah Safdar, MD, and John Leung, MD
Editor:
Basmah Safdar, MD
Editor:
John Leung, MD
Source
http://emedicine.com
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