We have defined the diagnosis of our patient based on the bedside examination. Our patient has acute pericarditis, because we observed the hallmark of that diagnosis. We heard a three-component friction rub. Now, certainly we suspected the diagnosis based on the history but, when we examined the patient, we heard at the lower left sternal edge [sounds], almost like that choo-choo train effect, because we heard a systolic and two diastolic components to the friction rub.

What is the cause of those three components? The cause is the rubbing together, if you will, of the pericardial surfaces that occurs in systole, as the heart moves, and occurs twice in diastole, as the heart moves. First, in early diastole, just at the peak of rapid filling, at the time of the third heart sound; and also in late diastole, at the time of pre-systolic filling due to atrial contraction at the time of the s4.

So, we defined the diagnosis based on a critical bedside finding, and we also did not observe on our bedside exam findings that were consistent with other causes of acute chest pain. Examples such as: dissimilar pulses or blood pressures from a patient with a dissection; ischemic bulging of the myocardium that you might find with an acute myocardial infarction; findings of acute pulmonary hypertension that you might find with a very large pulmonary embolism.

We’ve defined the diagnosis. We have not specifically defined the etiology, but we do know the category of diagnosis.

Now, patients who have pericarditis may develop complications, and those complications fall in several areas. To begin with, the disease may be recurrent, and when it is recurrent, you go back and listen very carefully in that patient who comes back with a history similar to their initial presetation, and you listen so hard for that pericardial rub which, again, is the hallmark of the disorder. The patient can develop effusion, which is simply stated, fluid between you and the heart, in terms of your bedside diagnosis. And what does that mean? It means when you go to feel the apical impulse, it may not be apparent, because of that cushion that is occurring between you and the heart. It means when you go to listen to the heart sounds, they may be muffled and distant.

Other complications particularly relate to the diastolic filling of the heart due to pericardial disease. In the first case, it’s an acute emergency: pericardial tamponade. And, in addition to difficulty defining the apical impulse or hearing the heart sounds, the neck veins may be quite elevated. The patient may become an absolutely acute emergency that is potentially curable by removing the fluid that is causing the tamponade.

And then a chronic, and yet curable, complication, potentially curable, of pericarditis. That is, constriction. In that case, you find the patient who presents to you with severe “congestive heart failure.” But again, potentially curable. But clues may be there. You look at the neck veins: very rapid “x” and “y” descent. You may hear a pericardial knock.

In summary, our patient’s diagnosis was defined by the bedside examination. We also did not find findings consistent with any other diagnosis associated with acute chest pain. And, finally, be on the alert in such patients for the complications we mentioned.