Date:
Patient:
主诉 (zhǔ訴) (Chief Complaint): Briefly describe the patient’s main reason for presentation, typically involving chest pain:
Sharp, stabbing, or pleuritic chest pain (worsened with deep inspiration, coughing, or lying flat)
May radiate to the neck, shoulders, or back
Pericardial friction rub (a scratchy sound heard on auscultation) – not always present
History of Present Illness:
Onset and duration of pain
Severity of pain (graded on a scale)
Associated symptoms:
Low-grade fever
Malaise (general feeling of discomfort)
Dyspnea (shortness of breath) – may occur in severe cases
Myalgias (muscle aches)
Arthralgias (joint pain)
Past medical history (recent viral illness, autoimmune disease, chest trauma, cardiac surgery)
Medications (current medications)
Physical Examination:
Vital signs (temperature, heart rate, blood pressure, respiratory rate) – May be slightly elevated with fever or tachycardia.
General examination: Assess for signs of respiratory distress (if present).
Cardiovascular examination:
Listen for pericardial friction rub (if present).
Assess for jugular venous distention (JVD) or peripheral edema (signs of heart failure – uncommon in acute pericarditis).
Laboratory Findings:
Complete blood count (CBC): May show leukocytosis (high white blood cell count) in some cases.
C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR): Elevated levels suggest inflammation, but are not specific for pericarditis.
Troponin: May be mildly elevated in some cases, but a very high level suggests myocardial involvement.
Viral serologies: May be tested to identify a potential viral cause (e.g., Coxsackievirus, adenovirus).
Autoimmune markers: May be tested if an autoimmune cause is suspected.
Imaging Studies:
Chest X-ray: May be normal or show signs of enlarged cardiac silhouette (rare in acute pericarditis).
Electrocardiogram (ECG): May show characteristic ST-segment changes and PR segment elevation in early stages.
Echocardiogram: Essential to confirm the diagnosis, assess for pericardial effusion (fluid collection around the heart), and evaluate cardiac function.
Assessment:
Summarize the findings and diagnose acute pericarditis based on clinical presentation, ECG changes, and echocardiogram findings.
Consider the severity of pericarditis (presence of effusion, hemodynamic compromise).
Identify the suspected cause of pericarditis (e.g., viral, idiopathic, autoimmune, post-pericardiotomy syndrome).
Plan:
Anti-inflammatory medications:
Nonsteroidal anti-inflammatory drugs (NSAIDs) are the mainstay of treatment for pain relief and inflammation.
Colchicine may be added to prevent recurrent attacks.
Corticosteroids may be used in severe cases or if NSAIDs are not tolerated.
Pain management: Administer pain medication as needed for symptom relief.
Treat underlying cause: Address specific causes like viral infection or autoimmune disease.
Monitor for complications: Pericardial effusion, cardiac tamponade, constrictive pericarditis.
Consultations:
Cardiology (may be needed for diagnosis, management, and monitoring).
Progress Notes:
Document daily assessments including vital signs, pain level, respiratory status, and presence of pericardial friction rub.
Note any changes in laboratory results and imaging studies (if repeated).
Update the plan as needed based on the patient’s progress and response to treatment.
Discharge Instructions (for patients with improving symptoms):
Follow-up appointments with a cardiologist to monitor recovery.
Continue medications as prescribed.
Instructions to return if symptoms worsen (increased chest pain, shortness of breath).
Disclaimer: This template is for informational purposes only and should not be used as a substitute for professional medical advice. Early diagnosis and treatment are crucial to prevent complications.