Case Study: A case of chest pain and breathlessness

A patient had chest pain which improved when he changed position. Dr Laurence Knott explains

One morning, Peter, aged 47, attended the surgery a letter which showed that he had attended A&E the previous night for treatment of left-sided chest pain. He had been diagnosed with a musculoskeletal condition and was prescribed diclofenac.

Although his condition had improved somewhat, I wrote him a sick note because he was continuing to experience considerable discomfort.

A few days later he was back as an emergency patient. The pain had worsened and was almost as bad as the night he went to hospital. It was centred in the same area (the precordium), but he was also experiencing pain in the left side of the neck and the left shoulder.

Peter had a history of mild asthma and at this stage was complaining of slight breathlessness. When he leaned back, during my physical examination of his chest, he winced in pain. Changing position affected his pain and it felt better when he sat up and leaned forward. Peter's lungs were clear and his peak flow was normal.

A cardiovascular system examination was unremarkable and he was apyrexial. I increased his analgesia and referred him for a chest X-ray and an ECG.

The following day Peter was back in my surgery with the results of his ECG. I listened to his chest and, although it was faint, I could just about discern the intense, grating sound of a pericardial friction rub, confirming the diagnosis of pericarditis.

The ECG showed no sign of low-voltage complexes to suggest a large effusion.

Pericorditis

Although bacterial cases of pericarditis do occur, the majority are viral. Minor viral symptoms, such as a runny nose, rash or diarrhoea, may precede chest pain.

The sound of the pericardial friction rub has variously been described as machine-like, or like a hair being rubbed between the fingers. An ECG typical of pericarditis will show generalised ST elevation in leads with an upright T wave.

Apart from chest or left shoulder pain there may be remarkably few other symptoms displayed.

Fever and, at times, a cough, may develop but these can be late manifestations of the condition. If present, the cough will normally improve by sitting up and leaning forward, as Peter demonstrated during examination.

Apart from the pericardial friction rub and occasional pyrexia, more often than not physical examination can offer unremarkable findings.

Cardiac tamponade

The accumulation of pericardial fluid may cause cardiac tamponade. This can be sudden and cause acute breathlessness.

If it does happen in a viral case, the onset is usually more subtle, with vague symptoms such as anxiety, altered mental status, worsening breathlessness and fatigue.

The classic physical signs, known as Beck's triad, are raised jugular venous pressure, hypotension and muffled heart sounds. Another significant sign to look for is pulsus paradoxus.

Management

The management of viral pericarditis is with anti-inflammatory medication and rest. Steroid therapy is rarely required. Cardiac tamponade requires immediate admission to hospital in order to carry out surgical drainage.

In this case, I sent Peter home with the warning to contact the practice if he felt unwell again, specifically if he got more breathless. I also suggested he tell his wife to contact us if he seemed confused. I reviewed Peter a week later when his chest X-ray had arrived and was normal.

It showed no suggestion of the enlarged cardiac silhouette that one would expect to see in the presence of a developing cardiac effusion.

Dr Laurence Knott is a GP in Enfield, Middlesex

LESSONS LEARNT
  
  • Pericarditis will show a typical ECG and distinctive chest noises.
  • Neck and chest pain will improve when patients change position.
  • Be aware of the development of a cardiac tamponade.
  • Viral pericarditis is treated with anti-inflammatory medication and rest.

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