Glossary of Primary Care: Infectious Heart Disease

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What are some factors that allow you to distiguish pain associated with an MI from pain in acute pericarditis?
Pericarditis pain: is relieved when patient leans forward, is pleuritic in nature (Hurts when patient breaths), the patient is young, and there is fever present
What is the big PE finding in acute pericarditis?
Friction rub! Have patient lean forward and exhale.
When looking at the EKG, what would you expect to see in acute pericarditis?
EKG is abnormal in 90% of cases-diffuse ST elevation in ALL leads. ST elevation is throughout whole EKG as opposed to MI which has STE in specific leads.
What is the treatment for acute pericarditis?
Self limited disease-
runs its course in 1 to 3 weeks
Pain relief with ASA or NSAIDS is biggest treatment.

Severe cases can use steroids, however, may start the inflammatory process over again when withdrawing the steroids. DO NOT USE FOR UNCOMPLICATED CASES!
What the big diagnostic symptoms for pericardial effusion?
Symptoms of pericardial effusion are from compression of adjacent structures-
Dysphagia (Compression of esophagus)
Dyspnea (Compression of lung)
Hoarseness (Compression of laryngeal nerve)-very common
Hiccups (Compression

Additionally, patient may complain of a dull constant ache in the left side of the chest.
In terms of diagnostic tests for pericardial effusion, which ones will give the best results to rule in a + diagnosis?
CXR: poor- need 250cc of fluid
EKG: demonstrates low voltage across all leads
What is the treatment for pericardial effustion?
Pericardiocentesis- don't go too deep with the needle! Insert needle under xiphoid and go into pericardial space. Can see elevated ST segments from damage to heart if you go in too far with needle.
What disease process could results from a patient having chest trauma and pericardial effusion?
What are the PE finding when diagnosising tamponade?
Physical Examination
*JVD-hallmark PE

*Systemic hypotension

*Small quiet heart on PE

If rapid tamponade then confusion and agitation. If slow development of tamponade, then fatigue and peripheral edema manifest.

Be sure and remember that patient’s O2 is down when they are confused.
How do we designate between cardiac tamponade and other cardiac conditions that cause low CO?
Cardiac catheterization with intracardiac and intrapericardial pressure. These measurements can differentiate between cardiac tamponade and other causes of low cardiac output.
If a patient presents with ascites and hepatomegaly without hepatic cirrhosis or an abdominal tumor and they have had repeated episodes of pericarditis, what disease state is most likely present?
Constrictive pericarditis!
Calcification of pericardium seen on CXR is indicative of what disease state?
Constrictive pericarditis!
What are the 3 means by which to classify infectious endocarditis?
1. By clinical course (Acute or insidious onset)

2. By host substrate (Native or Prosthetic Valve or IVDA)

2.By the specific infecting organism
What is the pathophysiology of enfectious endocarditis?
Turbulence allows platelets to come in; bacteria come in/”seeding”, calcium covers it all on valve. Strep viridens in non-IV drug users and staph. aureus in drug users.
How does the patient present differently in acute pericarditis compared to subacute pericarditis/
In Acute Bacterial Endocarditis there is an
acute, fulminant infection, with a highly virulent organism. The patient has high fever and shaking/chills- patient goes into cardiogenic and septic shock. Very often patient dies.

In subacute bacterial endocarditis
the disease process is insidious- the patient has lower grade fever with nonspecific symptoms of fatigue, anorexia, weakness, myalgias or night sweats.
Often mimics URI like influenza.
When examining a patient with subacute bacterial endocarditis, what PE finding would differentiate subacute from acute?
Subacute= murmur.
What are PE/CXR findings that are indicative of infectious endocarditis?
Development of CHF signs

Splinter hemorrhages: little micro-emboli that are vegetations attached to valves. These are seen a lot.

Janeway lesions: palpable erythemitus lesions on palms and on palms of the feet.

Osler nodes: split peasized nodules in pulp of nailbed in fingers and toes.

Roth spots: crescent shaped spots in eye. When vegetations break off and go up into eye you get hemorrhage.
In a patient with infectious endocarditis, what would expect to see on an EKG?

What 2-fold therapy would be implemented for the endocarditis?

4-6 weeks IV antibiotics usually with valve replacement
When a patient presents with myocarditis, what about this disease state makes it difficult to differentiate from an MI or HF?
Symptoms may include fatigue, dyspnea, precordial discomfort, or palpations.

Patient is also tachycardic and S4 is heard.
What results do you expect on the EKG in a patient with myocarditis?
Heart block and ST segment elevation!

EKG may show ST elevation or depression and T wave inversions. Myocardium is starting to get destroyed.

Atrial arrhythmias are also common along with transient first, second or third degree heart block. Because myocardium is starting to get destroyed, the block occurs.

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