CONFIRMING DIAGNOSIS Endomyocardial biopsy is rarely performed to diagnose myocarditis; the procedure is invasive and costly. A negative biopsy doesn’t exclude the diagnosis, and a repeat biopsy may be needed.
ECG typically shows diffuse ST-segment and T-wave abnormalities as in pericarditis, conduction defects (prolonged PR interval), and other supraventricular arrhythmias. Echocardiography demonstrates some degree of left ventricular dysfunction, and radionuclide scanning may identify inflammatory and necrotic changes characteristic of myocarditis.
Stool and throat cultures may identify bacteria.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Pericarditis:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Because pericarditis commonly coexists with other conditions, diagnosis of acute pericarditis depends on typical clinical features and elimination of other possible causes. The pericardial friction rub, a classic symptom, is a grating sound heard as the heart moves. It can usually be auscultated best during forced expiration, while the patient leans forward or is on his hands and knees in bed. It may have up to three components, corresponding to the timing of atrial systole, ventricular systole, and the rapid-filling phase of ventricular diastole. Occasionally, this friction rub is heard only briefly or not at all. Nevertheless, its presence, together with other characteristic features, is diagnostic of acute pericarditis. In addition, if acute pericarditis has caused very large pericardial effusions, physical examination reveals increased cardiac dullness and diminished or absent apical impulse and distant heart sounds.
Chest X-ray, echocardiogram, chest magnetic resonance imaging (MRI), heart MRI, heart computed tomography scan, and radionuclide scanning can detect fluid that has accumulated in the pericardial sac. They may also show enlargement of the heart and signs of inflammation or scarring, depending on the cause of pericarditis.
In patients with chronic pericarditis, acute inflammation or effusions don’t occur — only restricted cardiac filling.
Laboratory results reflect inflammation and may identify its cause:
❑ normal or elevated white blood cell count, especially in infectious pericarditis
❑ elevated erythrocyte sedimentation rate
❑ slightly elevated cardiac enzyme levels with associated myocarditis
❑ culture of pericardial fluid obtained by open surgical drainage or cardiocentesis (sometimes identifies a causative organism in bacterial or fungal pericarditis)
❑ electrocardiography showing the following changes in acute pericarditis: elevation of ST segments in the standard limb leads and most precordial leads without significant changes in QRS morphology that occur with MI, atrial ectopic rhythms such as atrial fibrillation and, in pericardial effusion, diminished QRS voltage.
Other pertinent laboratory data include blood urea nitrogen levels to check for uremia, antistreptolysin-O titers to detect rheumatic fever, and a purified protein derivative skin test to check for tuberculosis. In pericardial effusion, echocardiography is diagnostic when it shows an echo-free space between the ventricular wall and the pericardium.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Pericardial friction rub:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Obtain a complete medical history, noting especially cardiac dysfunction. Has the patient recently had a myocardial infarction or cardiac surgery? Has he ever had pericarditis or rheumatic disorder, such as rheumatoid arthritis or systemic lupus erythematosus? Does he have chronic renal failure or an infection? If the patient complains of chest pain, ask him to describe its character and location. What relieves the pain? What worsens it?
Take the patient’s vital signs, noting especially hypotension, tachycardia, irregular pulse, tachypnea, and fever. Inspect for jugular vein distention, edema, ascites, and hepatomegaly. Auscultate the lungs for crackles.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Pericardial Friction Rub:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
This is a very important element in the evaluation of a friction rub.
A. Pain characteristics. Where is the pain? What is the nature of the pain? Does the pain radiate? Does body position affect the pain? Are systemic symptoms present?
1. The pain of AP is typically precordial and sharp; it can worsen with recumbency, movement, inspiration, coughing, or swallowing.
2. Pain can radiate to the trapezius ridge, a symptom characteristic of AP (1,2).
3. Fever, myalgias, and malaise may be present, especially with viral AP (Chapter 2.6).
B. Other symptoms. AP can complicate several serious diseases. Examples of “red flags” in the history include substernal chest pressure (myocardial infarction), “tearing” pain (aortic dissection), weight loss (malignancy), productive cough (pneumonia with purulent pericarditis), or hemoptysis (tuberculosis). Patients with viral or idiopathic AP typically do not have the aforementioned symptoms.
C. Past medical history. Is there a history of recent pericardiotomy? Is there a history of renal failure or hemodialysis? Has there been a previous diagnosis of collagen vascular disease? Noting any prior illnesses associated with AP may assist in the diagnosis of a rub.
D. Drug history. Drugs associated with AP include hydralazine, procainamide, minoxidil, cromolyn, and isoniazid (2).
Physical examination
A. Vital signs. Fever may be present with viral AP. Hypotension or pulsus paradoxus can occur with a large pericardial effusion or pericardial tamponade. Tachycardia may be caused by fever or tamponade (Chapter 7.12).
B. Cardiac auscultation. A quiet room is essential. The pathognomonic physical finding of AP is the pericardial friction rub that has been likened to creaking leather or a scratching sound (1–3). The rub may be evanescent and vary in intensity; hence, multiple attempts should be made to elicit this finding. The rub is best heard with the stethoscope diaphragm firmly applied to the chest wall at the left-lower sternal border at end-inspiration (2). Having the patient lean forward may be helpful. The classic friction rub occurs in three phases: atrial systole, ventricular systole, and ventricular diastole. However, eliciting all three phases is uncommon. The presence of a rub does not exclude a large pericardial effusion or cardiac tamponade (2,3).
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Endocarditis:
Diagnosis
(Handbook of Diseases)
Three or more blood cultures in a 24- to 48-hour period identify the causative organism in up to 90% of patients. The remaining 10% may have negative blood cultures, possibly suggesting fungal infection or infections that are difficult to diagnose such as Haemophilus parainfluenzae. Other abnormal but nonspecific laboratory test results include:
❑ normal or elevated white blood cell count
❑ abnormal histiocytes (macrophages)
❑ elevated erythrocyte sedimentation rate
❑ normocytic, normochromic anemia (in 70% to 90% of endocarditis cases)
❑ positive serum rheumatoid factor (in about one-half of all patients with endocarditis after the disease is present for 3 to 6 weeks).
Echocardiography may identify valvular damage. Transesophageal echocardiography allows visualization of cardiac structures. Electrocardiography may show atrial fibrillation and other arrhythmias that accompany valvular disease.
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Source: Handbook of Diseases, 2003
Myocarditis:
Diagnosis
(Handbook of Diseases)
The patient history commonly reveals recent febrile upper respiratory tract infection, viral pharyngitis, or tonsillitis. A physical examination shows supraventricular and ventricular arrhythmias, third and fourth heart sounds, a faint first heart sound, possibly a murmur of mitral insufficiency (from papillary muscle dysfunction) and, if pericarditis is present, a pericardial friction rub.
ECG typically shows diffuse STsegment and T-wave abnormalities (as in pericarditis), conduction defects (prolonged PR interval), and other supraventricular arrhythmias.
Echocardiography may show a weak heart muscle, an enlarged heart, or fluid surrounding the heart.
Stool and throat cultures may identify the causative bacteria. An endomyocardial biopsy can confirm the diagnosis, but it’s rarely performed.
Laboratory tests can’t unequivocally confirm myocarditis, but the following findings support this diagnosis:
❑ Cardiac enzyme levels (creatine kinase [CK], the CK-MB isoenzyme, aspartate aminotransferase, and lactate dehydrogenase) are elevated.
❑ White blood cell count and erythrocyte sedimentation rate are increased.
❑ Antibody titers (such as antistreptolysin O titer in rheumatic fever) are
elevated.
❑ Blood cultures may indicate infection.
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Source: Handbook of Diseases, 2003
Pericarditis:
Diagnosis
(Handbook of Diseases)
Because pericarditis often coexists with other conditions, diagnosis of acute pericarditis depends on typical clinical features and elimination of other possible causes. It may be detected with X-ray, echocardiogram, magnetic resonance imaging, computed tomography, and coronary angiography. These tests may show scarring, contracture of the pericardium, or enlargement of the heart.
CLINICAL TIP: A classic symptom, the pericardial friction rub, is a grating sound heard as the heart moves. It can usually be auscultated best during forced expiration, with the patient leaning forward or resting on his hands and knees in the bed.
Pericardial friction rub may have up to three components, corresponding to the timing of atrial systole, ventricular systole, and the rapid-filling phase of ventricular diastole, Occasionally, it’s heard only briefly or not at all. Nevertheless, its presence, together with other characteristic features, is diagnostic of acute pericarditis.
In addition, if acute pericarditis has caused large pericardial effusions, the physical examination reveals increased cardiac dullness and diminished or absent apical impulse and distant heart sounds. Acute inflammation or effusions don’t occur in patients with chronic pericarditis — only those with restricted cardiac filling.
Laboratory results reflect inflammation and may identify its cause:
❑ normal or elevated white blood cell count, especially in infectious pericarditis
❑ slightly elevated cardiac enzyme levels with associated myocarditis
❑ culture of pericardial fluid obtained by open surgical drainage or cardiocentesis (sometimes identifies a causative organism in bacterial or fungal pericarditis).
Electrocardiography shows the following changes in acute pericarditis: elevation of ST segments in the standard limb leads and most precordial leads without the significant changes in QRS-complex morphology that occur with an MI, atrial ectopic rhythms such as atrial fibrillation, and diminished QRS complex in pericardial effusion.
Other pertinent laboratory studies include blood urea nitrogen level to check for uremia, antistreptolysin O titers to detect rheumatic fever, and a purified protein derivative skin test to check for tuberculosis. In pericardial effusion, echocardiography is diagnostic when it shows an echo-free space between the ventricular wall and the pericardium.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Pericardial friction rub:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Obtain a complete medical history, noting especially cardiac dysfunction. Has the patient recently had a myocardial infarction or cardiac surgery? Has he ever had pericarditis or rheumatic disorder, such as rheumatoid arthritis or systemic lupus erythematosus? Does he have chronic renal failure or an infection? If the patient
complains of chest pain, ask him to describe its character and location. What relieves the pain? What worsens it?
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Pericardial friction rub:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Obtain a complete medical history, noting especially cardiac dysfunction. Has the patient recently had a myocardial infarction or cardiac surgery? Has he ever had pericarditis or a rheumatic disorder, such as rheumatoid arthritis or systemic lupus erythematosus? Does he have chronic renal failure or an infection? If the patient complains of chest pain, ask him to describe its character and location. What relieves the pain? What worsens it?
Take the patient's vital signs, noting especially hypotension, tachycardia, an irregular pulse, tachypnea, and fever. Inspect for jugular vein distention, edema, ascites, and hepatomegaly. Auscultate the lungs for crackles. (See Comparing auscultation findings, pages 474 and 475.)
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
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