MEDizzy - A 35-year-old male complains of substernal chest pain

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Cardiology

A 35-year-old male complains of substernal chest pain aggravated by inspiration and relieved by sitting up. Lung fields are clear to auscultation, and heart sounds are somewhat distant. Chest x-ray shows an enlarged cardiac silhouette. Which of the following is the best next step in evaluation?

ExplanationThe patient’s pleuritic chest pain that is relieved by sitting up is classic for pericarditis. A pericardial friction rub may initially be present, then disappear, with the heart sounds becoming fainter as an effusion develops. Lung sounds are clear; rales or basilar dullness suggest an alternate diagnosis. An enlarged cardiac silhouette without other chest x-ray findings of heart failure suggests pericardial effusion. Echocardiography is the most sensitive and specific way of determining whether pericardial fluid is present. The effusion appears as an echo-free space between the moving epicardium and stationary pericardium. Lateral decubitus chest film would show pleural, not pericardial, fluid. It is unnecessary to per- form cardiac catheterization for the purpose of evaluating pericardial effusion. A stress test is helpful in coronary artery disease, but not pericarditis. ECG may show diffuse ST segment elevation or PR depression, but an echocardiogram is more sensitive in the diagnosis of pericardial effusion.