Pericardial Disease

Question 1

Most common pathologic process involving the pericardium

Answer 1

Acute Pericarditis

Question 2

A 35-year-old man presents with chest pain that worsens when lying flat and is relieved by sitting forward. He describes the pain as sharp and radiating to his left shoulder. He denies shortness of breath. On physical examination, a scratching sound is heard during auscultation. Which of the following findings on ECG is most likely in this patient?

A. ST segment depression in all leads
B. Widespread ST segment elevation with upward concavity
C. Q waves and loss of R-wave amplitude
D. Normal ECG findings

Answer 2

B

Question 3

A 50-year-old man presents with retrosternal chest pain that worsens with inspiration and improves when sitting up. Cardiac biomarkers are mildly elevated. Which of the following best distinguishes acute pericarditis from acute myocardial infarction in this patient?

A. Presence of pleuritic chest pain
B. Widespread concave ST segment elevation on ECG
C. Elevation of cardiac biomarkers
D. Positive troponin with no T-wave inversion

Answer 3

B

Question 4

A 45-year-old man presents with severe retrosternal chest pain that radiates to his left shoulder. The pain worsens when lying supine and improves when sitting up and leaning forward. On auscultation, a scratching sound is heard. Which of the following findings on ECG would most likely support the diagnosis of acute pericarditis?

A. ST-segment elevations with upward concavity and PR-segment depression.
B. ST-segment elevations with upward convexity and prominent Q waves.
C. Reciprocal ST-segment depressions in most leads.
D. Normal ECG findings.

Answer 4

A

Question 5

A 50-year-old man with a recent viral illness presents with sharp, pleuritic chest pain. Which of the following features distinguishes acute pericarditis from myocardial infarction?

A. Pain relieved by sitting up and leaning forward.
B. Elevated troponin levels.
C. ST-segment elevation on ECG.
D. Pain radiating to the left arm

Answer 5

A

Question 6

A 65-year-old patient presents with chest pain and an ECG showing diffuse ST-segment elevation and PR-segment depression. His chest pain improves when sitting upright. Which of the following additional findings is most likely on auscultation?

A. Pericardial friction rub.
B. S3 gallop.
C. Distant heart sounds.
D. Continuous murmur.

Answer 6

A

Question 7

A 45-year-old man presents with severe chest pain that is retrosternal, sharp, and worsens with inspiration. The pain improves when he sits up and leans forward. On auscultation, a friction rub is heard. Which of the following is the most likely diagnosis?

A. Acute Myocardial Infarction (AMI)
B. Acute Pericarditis
C. Pulmonary Embolism
D. Aortic Dissection

Answer 7

B

Question 8

A 38-year-old woman presents with chest pain radiating to her trapezius ridge. Her ECG shows widespread ST elevation with upward concavity and PR depression. What stage of acute pericarditis ECG evolution does this represent?

A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4

Answer 8

A

Question 9

A patient presents with a pericardial friction rub and a patch of dullness, increased fremitus, and egophony beneath the left scapula. What is the term for this clinical sign?

A. Beck’s triad
B. Ewart’s sign
C. Levine’s sign
D. Kussmaul’s sign

Answer 9

B

Question 10

A patient with acute pericarditis develops faint heart sounds, electrical alternans, and hypotension. Which complication should be suspected?

A. Cardiac tamponade
B. Left ventricular aneurysm
C. Massive pulmonary embolism
D. Congestive heart failure

Answer 10

A

Question 11

A patient with acute pericarditis is found to have modestly elevated troponin and creatine kinase-MB (CK-MB). What is the likely cause of these biomarker elevations?

A. Myocardial infarction
B. Concomitant epicardial involvement
C. Large pericardial effusion causing cardiac compression
D. Laboratory error

Answer 11

B

Question 12

A 50-year-old man presents with chest pain and an ECG showing PR segment depression and widespread ST elevation. Which additional physical finding supports the diagnosis of acute pericarditis?

A. Dullness and increased fremitus beneath the left scapula
B. Persistent splitting of S2
C. Presence of a continuous murmur
D. Pleuritic chest pain with dyspne

Answer 12

A

Question 13

Most widely used imaging technique [Acute Pericarditis]

Answer 13

Echocardiography

Question 14

Detects pericardial effusion [Acute Pericarditis]

Answer 14

MRI

Question 15

Predictors of poor prognosis in Acute Pericarditis

Answer 15

Fever >38°C.
Subacute onset.
Large pericardial effusion.

Question 16

Hospitalization is advised [Acute Pericarditis]

Answer 16

Suspected specific causes (e.g., tuberculosis, neoplastic disease, bacterial infection).

Question 17

A 40-year-old man is diagnosed with acute idiopathic pericarditis. He is started on ibuprofen 600 mg three times daily. Which of the following additional treatments is most appropriate to reduce the risk of recurrence?

A. Prednisone 1 mg/kg per day for 1 week
B. Colchicine 0.5 mg twice daily for 3 months
C. Omeprazole 40 mg daily for 3 months
D. Azathioprine 50 mg daily

Answer 17

B

Question 18

Which of the following is an indication for hospitalization in a patient with acute pericarditis?

A. Fever of 37.5°C and mild pericardial effusion
B. Suspected neoplastic pericarditis
C. Chest pain relieved by NSAIDs and colchicine
D. Pericarditis duration of 2 weeks with no complications

Answer 18

B

When specific causes (tuberculosis, neoplastic disease, bacterial infection) are suspected, or if any of the predictors of poor prognosis (fever >38°C, subacute onset, or large pericardial effusion) are present, hospitalization is advisable.

Question 19

A 55-year-old man with acute pericarditis is started on NSAIDs but continues to have symptoms. Prednisone is initiated at 1 mg/kg per day. Which of the following is the most significant drawback of using glucocorticoids in this condition?

A. Increased risk of gastrointestinal bleeding
B. Risk of myopathy
C. Increased risk of recurrence
D. Risk of pericardial constriction

Answer 19

C

Question 20

A patient with acute pericarditis has multiple recurrences despite treatment with NSAIDs and colchicine and not controlled by prednisone. Which of the following is a reported benefit in cases resistant to conventional treatment?

A. Anakinra
B. Low-dose aspirin
C. Warfarin
D. High-dose glucocorticoids

Answer 20

A

Question 21

A 45-year-old man presents with hypotension, muffled heart sounds, and jugular venous distention. His jugular venous waveform reveals a prominent x descent and an absent y descent. What is the most likely diagnosis?

A. Constrictive pericarditis
B. Cardiac tamponade
C. Pulmonary embolism
D. Acute myocardial infarction

Answer 21

B

Question 22

A patient with rapid onset dyspnea and hypotension is found to have reduced amplitude of QRS complexes and electrical alternans on ECG. Which of the following conditions should be suspected?

A. Acute pericarditis
B. Atrial fibrillation
C. Cardiac tamponade
D. Constrictive pericarditis

Answer 22

C

Question 23

What is the minimum amount of pericardial fluid may produce cardiac tamponade

A. 50–100 mL
B. 200 mL
C. 500 mL
D. >2000 mL

Answer 23

B

Question 24

A patient with jugular venous distention and muffled heart sounds is found to have pulsus paradoxus and electrical alternans on ECG. Which of the following conditions is the most likely diagnosis?

A. Cardiac tamponade
B. Constrictive pericarditis
C. Right ventricular myocardial infarction
D. Restrictive cardiomyopathy

Answer 24

A

Question 25

Which of the following is a distinguishing clinical feature of constrictive pericarditis compared to cardiac tamponade? A. Absent y descent in the jugular venous waveform B. Kussmaul’s sign C. Electrical alternans on ECG D. Small pericardial effusion on echocardiogram

Answer 25

B

Question 26

A patient with acute chest symptoms is evaluated with echocardiography, which reveals a thickened pericardium but no pericardial effusion. What is the most likely diagnosis? A. Cardiac tamponade B. Constrictive pericarditis C. Effusive constrictive pericarditis D. Right ventricular myocardial infarction

Answer 26

B

Question 27

Which of the following echocardiographic findings is most consistent with cardiac tamponade? A. Thickened pericardium B. No equalization of diastolic pressures C. Small right ventricular size D. No significant respiratory variation in flow velocity

Answer 27

C No thickened pericardium Equalization of diastolic pressure Exaggerated respiratory variation in flow velocity

Question 28

A patient presents with a thickened pericardium, prominent y descent in the jugular venous waveform, and pericardial knock. Which of the following is the most likely diagnosis? A. Cardiac tamponade B. Constrictive pericarditis C. Effusive constrictive pericarditis D. Restrictive cardiomyopathy

Answer 28

B

Question 29

A 50-year-old man presents with dyspnea and hypotension. On physical examination, his arterial pulse weakens during inspiration. What is the best method to confirm the presence of a paradoxical pulse? A. Palpation of the radial pulse during inspiration B. Sphygmomanometric measurement of systolic pressure during slow respiration C. Auscultation of heart sounds during inspiration D. Continuous ECG monitoring during respiration

Answer 29

B

Question 30

What is the physiological mechanism underlying paradoxical pulse in cardiac tamponade? A. Leftward septal bulging during inspiration reduces left ventricular filling and stroke volume B. Increased pericardial compliance enhances right ventricular filling C. Right ventricular infarction impairs systolic function D. Compression of the pulmonary veins decreases right ventricular preload

Answer 30

A

Question 31

A patient with suspected cardiac tamponade undergoes Doppler echocardiography. Which of the following Doppler findings supports the diagnosis? A. Increased pulmonic vein and mitral flow velocities during inspiration B. Decreased tricuspid and pulmonic valve flow velocities during inspiration C. Decreased pulmonic vein, mitral, and aortic flow velocities during inspiration D. Symmetrical changes in flow velocities across all cardiac valves during respiration

Answer 31

C In cardiac tamponade, Doppler echocardiography shows decreased pulmonic vein, mitral, and aortic flow velocities during inspiration, along with increased tricuspid and pulmonic valve flow velocities.

Question 32

A 45-year-old man with a history of pericarditis presents with jugular venous distention and hypotension. Echocardiography reveals a large pericardial effusion and diastolic collapse of the right ventricle. What is the next best step in management? A. Administer intravenous diuretics B. Immediate pericardiocentesis under echocardiographic guidance C. Start intravenous corticosteroids D. Observe with serial echocardiography

Answer 32

B

Question 33

A patient with recurrent tamponade is scheduled for surgical intervention after repeated pericardiocentesis. What is the most appropriate procedure to manage this condition? A. Subxiphoid thoracotomy B. Transesophageal echocardiography-guided catheter placement C. Balloon pericardiotomy D. Coronary artery bypass surgery

Answer 33

A

Question 34

Pericardial fluid obtained during pericardiocentesis appears bloody. In a patient living in a developing country, which of the following is the most likely cause? A. Cardiac injury B. Tuberculosis C. Renal failure D. Neoplasm

Answer 34

B

Question 35

A patient is suspected to have chronic constrictive pericarditis. Which of the following hemodynamic findings on cardiac catheterization would support the diagnosis? A. Continuous elevation of ventricular filling pressures throughout diastole B. Square root sign in ventricular pressure during diastole C. Elevated atrial pressures with an absent y descent D. Normal end-diastolic pressures in both ventricles

Answer 35

B

Question 36

_____ is the only definitive treatment of constrictive pericarditis and should be as complete as possible.

Answer 36

Pericardial resection