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Advanced Emergency Nursing Journal Vol. 32, No. 2, pp. 127–134 Copyright c 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Cases OF NOTE Column Editor: Theresa M. Campo, DNP, RN, APN, NP-C

Getting to the of Back and Shoulder Pain Kathleen Bradbury-Golas, DNP, APN, NP-C, ACNS-BC Theresa M. Campo, DNP, RN, APN, NP-C Anthony Chiccarine, DO, FACEP

Abstract A healthy male presents to the emergency department with common musculoskeletal complaints that have shown no improvement after 10 days of conservative management. The emergency department provider notes a and the patient confirms new onset for 1 day. After a comprehensive workup, the patient is admitted to the hospital. The purpose of this case presentation is to provide advanced practice nurses with information on the manifestations of what is initially felt to be musculoskeletal complaints. This article also emphasizes the need for an astute review of this patient’s “” vital signs and other presenting that will assist the advanced practice nurse in making an accurate diagnosis so as to provide appropriate patient management. Key words: , , , pericardial , tachycardia

USCULOSKELETAL COMPLAINTS different diagnosis than one would expect are commonly seen in the quick with back and shoulder pain. Mcare (QC) and emergency care setting. Having a keen awareness of not only CASE FOR REVIEW the patient’s complaint but also the vital signs and other presenting signs and symptoms are A 39-year-old man presented to the emer- of extreme importance. In the case presented gency department (ED) with a complaint of in this article, the provider’s recognition pain in the upper back between the shoul- of abnormal vital signs led to a completely der blades for 1 week. He had been seen by his primary care provider 10 days before com- ing to the ED and was given an intramuscular Author Affiliations: School of Health Sciences, The Richard Stockton College of New Jersey, Pomona (Dr injection, hydrocodone and acetaminophen Bradbury-Golas), Shore Memorial Hospital, Somers (Vicodin) and cyclobenzaprine (Flexeril). The Point, New Jersey (Dr Campo and Mr Chiccarine). patient reported that a was Corresponding Author: Kathleen Bradbury-Golas, negative for infiltrates. The patient reported DNP, APN, NP-C, ACNS-BC, School of Health Sciences, increased severity of symptoms prior to the The Richard Stockton College of New Jersey, PO Box 195, Jimmie Leeds Rd, Pomona, NJ 082410 (Bradbury- ED visit. The pain radiated to the left shoul- [email protected]). der. This patient was assigned an Emergency

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Severity Index score of four and was triaged Gastrointestinal. No masses. Bowel sounds to the QC area of the ED. in all four quadrants. Nontender, nondis- The patient’s past medical history was sig- tended abdomen. nificant for gastroesophageal reflux disease, Genitourinary. Unremarkable. and current medications include lansoprazole Pelvis. Unremarkable. (Prevacid) 30 mg daily, hydrocodone and ac- Extremities. Unremarkable. etaminophen (Vicodin), and cyclobenzaprine Musculoskeletal/Extremities. Bilateral (Flexeril). paraspinal tenderness—thoracic region. No The patient denied any food or medication spasm, costovertebral angle tenderness, allergies, unsure of last tetanus immunization, or limited range of motion. Strength 5/5 smokes a half a pack of cigarettes daily, drinks bilaterally. alcohol three to four times a week, and de- nied illicit drug use. Significant family medical Neurologic. Motor and sensory normal. Deep + history included a father who had received a tendon reflexes were 2 bilateral ankles and = coronary bypass graft at 78 years of age. biceps. Glascow Coma Scale score 15. Cra- nial nerves II–XII grossly intact. HISTORY OF PRESENTING ILLNESS Psychiatric. Unremarkable. Emergency department course The patient presented in no apparent distress but is complaining of increasing thoracic back The provider ordered the following: pain radiating to the left shoulder. The pain Cervical and thoracic spine plain was described as sharp and increased with left radiographs—three views arm movement. There was no numbness to Computed tomography (CT) chest (to rule the left arm and fingers. The patient has ex- out ) perienced shortness of breath the day before 12-lead electrocardiogram (ECG) arriving to the ED. Heart monitor Laboratory testing PATIENT ASSESSMENT Basic metabolic panel Complete count The patient presented awake, alert, and Sedimentation rate oriented. Vital signs are as follows: heart Troponin rate, 124 beats/min; blood pressure, 128/82 PT/INR/PTT mmHg; respiratory rate, 20 per min; tempera- Medications ◦ ◦ ture, 36.9 C (98.4 F) orally; and oxime- Ketoralac (Toradol) 30 mg intravenous try, 97% room air. Normal saline (0.9%) 500 ml/hr followed by Skin. Warm, dry, and pink. 100 ml/hr The results of the diagnostic testing are as fol- Head, eyes, ears, nose, and throat. head nor- lows: mocephalic, pupils equal, round, reactive to light and accommodation, extraocular move- ECG. with nonspecific ments intact, free of icterus and pale conjunc- abnormality in the anterior leads tiva. (Figure 1). Ears, nose, and throat/mouth unremarkable. Cervical and thoracic spine. Normal exami- nation. Neck. Supple no masses, lesions, or lym- CT chest. No aortic dissection or dilatation. phadenopathy. Full range of motion. with pericardial effusion up to Chest/respiratory lungs were clear to auscul- 1.2 cm linear atelectasis or infiltrate at lung tation in all fields. No rhonchi, wheeze, or bases. Trace pleural effusions (Figure 3). rub. CT abdomen. Prior cholecystectomy and ap- Heart.S1–S2 with no murmurs, gallops, or rub pendectomy. Abdominal aorta normal. Mild were auscultated. splenomegaly. LWW/AENJ TME200069 April 26, 2010 11:12 Char Count= 0

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Figure 1. Initial electrocardiogram.

Figure 2. Computed tomography angiography chest emergency department. LWW/AENJ TME200069 April 26, 2010 11:12 Char Count= 0

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Figure 3. Initial chest radiograph.

Complete blood count. White blood cell Initial chest radiography was repeated 16.7, hemoglobin 14.5, hematocrit 43.2, and twice during admission showing bilateral platelets 548. pleural effusions and cardiomegaly (Figure 3). Basic metabolic panel. Within normal limits. Workup for and human Sedimentation rate.19 immunodeficiency virus was negative. Lyme titer was negative. Blood cultures were nega- PT/INR/PTT. 11.4/1.1/29.6 tive. Repeat echocardiogram 3 days after ad- Consultation. A cardiology consult was initi- mission showed improvement. Medications ated and stat bedside noninvasive echocardio- included nonsteroidal anti-inflammatory pain gram was ordered. The result of the echocar- medication, a proton pump inhibitor for his- diogram was circumferential pericardial effu- tory of gastroesophageal reflux disease and sion measuring 1.2 cm considered to be small a β-blocker for tachycardia. The patient was to moderate; mild concentric left ventricu- discharged 5 days after admission with the lar hypertrophy. The aorta, bilateral atria, and discharge diagnoses of (1) pericarditis with ventrical were normal size. Left ventricular pericardial effusion, resolved; (2) left shoul- systolic and diastolic functions were normal. der pain possibly secondary to pericarditis, Ejection fraction was 65% and all valves were resolved; (3) tachycardia; and (4) gastroe- normal. sophageal reflux disease.

ED Patient Management ANATOMY AND PHYSIOLOGY This patient was administered levofloxacin OF THE (Levaquin) 500 mg intravenously and ibupro- fen 600 mg orally. The patient was admitted to The pericardium consists of two layers that the hospital for repeat echocardiograms and envelop the heart. The visceral layer, or epi- further treatment. cardium, is single layer membrane composed LWW/AENJ TME200069 April 26, 2010 11:12 Char Count= 0

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of mesothelial cells that adhere to the my- Table 1. Causes of pericardial effusion ocardium. The parietal layer is composed mainly of collagen and elastin fibers. The Viral, bacterial, fungal or parasitic infections two layers are separated by a potential space Idiopathic (about one third of that can contain up to approximately 50 ml cases) of serous fluid. The parietal pericardium at- Inflammation following heart surgery or taches to the diaphragm, sternum, and other myocardial infarctions (Dressler’s structures by ligaments that ensure a relatively syndrome) fixed position of the heart. The structures Autoimmune disorders, such as rheumatoid are innervated by the mammary artery and arthritis or systemic lupus erythematosus phrenic nerve (Braunwald, Zipes, Libby, & due to Bonow, 2004; Marx, Hockenberger, & Walls, 2010). Human immunodeficiency virus /acquired immunodeficiency syndrome The pericardium has numerous functions. Metastasis from lung , breast cancer, These functions include lubrication of the leukemia, Hodgkin’s disease, heart, heart position, prevention of infection non-Hodgkin’s lymphoma and overdilatation, atrial filling, and mainte- Radiation therapy and chemotherapy nance of a normal pressure-volume relation- Trauma/puncture wound ship of the cardiac chambers. Abnormal accu- Specific prescription medications, such as mulation of fluid can occur with obstruction hydralazine, isoniazid, phenytoin of drainage from the venous and lymphatic system (Braunwald et al., 2004; Marx, et al., 2010) gender, or age, though it is most common to occur between 40 and 50 years of age. BACKGROUND A pericardial effusion is defined as the pres- CLINICAL MANIFESTATIONS ence of an abnormal amount and/or charac- ter of fluid in the pericardial space. It is usu- Clinical manifestations of a pericardial effu- ally caused by an inflammatory process, in sion are dependent on the rate of fluid ac- response to disease or . Some specific cumulation in the pericardial sac. Symptoms causes of pericardial effusion can be viewed of slow progressing effusions (even up to in Table 1 (Strimel, Sovari, Assadi, & Kocheril, 2 L of fluid) may be nonexistent, with rapid 2009; Sugiura, Kataoka, Matsymura, Takeuchi, accumulation of up to 80 ml causing severe & Doi, 2009). symptoms. Manifestations of pericardial effu- In addition, pericardial effusion may also sion include dyspnea, orthopnea, , occur when the flow of pericardial fluids is cough, painful breathing, especially when ly- blocked or when blood accumulates within ing down, and dizziness and syncope, all very the pericardium, as with or nonspecific to the disease process occurring trauma (Table 1). In many cases, the cause of (Braunwald et al., 2004; Marx et al., 2010; pericardial effusion can be determined, but in Strimel et al., 2009). others it is not apparent even with a thorough The advanced practice nurse (APN) should diagnostic evaluation. specifically question the patient about subjec- Most small effusions are asymptomatic, be- tive cardiopulmonary symptoms. Should a pa- ing found only on autopsy. Malignant neo- tient report any of the above symptoms, the plasms have a high prevalence rate, up to 21%, APN should also look for the following signs with human immunodeficiency virus show- on examination. ing 5%–43% prevalence. The development of • pericardial effusion is not specific to race, • Tachycardia LWW/AENJ TME200069 April 26, 2010 11:12 Char Count= 0

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• Tachypnea Table 2. Laboratory and imaging studies for • Tubular breath sounds over left lung base pericardial effusion diagnosis or axilla • Poor peripheral , edema Laboratory studies Imaging studies • Signs of impending or fulminate include the following: Electrolytes Chest radiography • , jugular distention, Complete blood muffled (Beck’s triad) count with • Decrease in systolic blood pressure differential more than 10 mmHg with inspiration Cardiac enzymes Echocardiography (). (Braunwald et al., Thyroid stimulating Transesophageal hormone echocardiography 2004; Marx et al., 2010; Strimel et al., Specific Computed 2009) rheumatologic tomography Advanced practice nurses need to recog- studies, such as nize that patient presentation will be affected rheumatoid factor by the degree of cardiac output and there- Magnetic resonance fore the severity of effusion. Besides pleural analysis: lactic imaging effusion, other differential diagnoses should dehydrogenase, be considered. Some examples of these diag- total protein, cell noses include but are not limited to cardiomy- count, gram stain, opathy, , pulmonary edema, culture, hematocrit and pulmonary . Pericarditis is considered to be the most common associated diagnosis with pericar- is apparent with a minimum of 200–250 ml dial effusion. It is associated with severe of pericardial fluid but will usually have nor- pleuritic sharp chest pain, which may radi- mal pulmonary vasculature. Another reliable ate to the trapezius region. The pain is re- sign that can be viewed on chest radiography lieved by sitting forward and is worsened is a pericardial fat pad sign. The pericardial fat when the patient lies down. A recent his- pad sign represents separation of the parietal tory of fever, cough, dyspnea, and sometimes pericardial fat from the epicardium and is vi- hiccoughs may be associated symptoms of sualized as a linear lucency between the ante- a patient presenting with pericarditis. Physi- rior surface of the heart and chest wall (Braun- cal examination may reveal patient with low- wald et al., 2004). However, radiography is grade fever that is anxious, with tachycar- not the most reliable method of establishing a dia and a friction rub that can be heard. diagnosis. The friction rub consists of the three com- Imaging ponents of ventricular , early diastolic filling, and atrial contraction and is heard Echocardiography is the noninvasive modal- loudest at the left sterna border with the ity of choice for confirming the diagnosis of patient leaning forward (Braunwald et al., pericardial effusion. This modality differen- 2004). tiates pericardial fluid from increased heart chamber size and evaluating wall motion ab- normalities. Small effusions may begin over DIAGNOSTIC EVALUATION the left and progress anteriorly, lat- In order to determine the cause of the erally, and behind the left atrium becom- patient’s clinical manifestations, a complete ing circumferential. The increase in fluid cir- workup should be obtained (Table 2). A base- cumferentially can lead to cardiac tamponade line chest radiograph should be obtained, (Braunwald et al., 2004). Cardiac tamponade which shows an enlarged cardiac silhouette is distinguished on echocardiogram as dias- (water bottle or flask-shaped). Cardiomegaly tolic collapse usually beginning at the right LWW/AENJ TME200069 April 26, 2010 11:12 Char Count= 0

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ventricular wall. Overall sensitivity in identify- Table 3. Treatment modalities for underlying ing pericardial effusion may be as high as 96% pericarditis (Wills, Young, & White, 2010). Computed tomography and magnetic reso- Aspirin/nonsteroidal antiinflammatory agents nance imaging can also be used for technically Colchicine difficult echocardiogram but are not first-line Steroids diagnostic studies. Both modalities are useful Antibiotics adjuncts to echocardiography giving more de- tailed information on the nature of the peri- cardial fluid. However, neither CT nor reso- 3 per 100,000 patients per year (Wills et al., nance imaging is recommended in patients 2010). Other treatment modalities are geared requiring prompt management and treatment toward the actual cause of the pericardial ef- decisions. (Braunwald et al., 2004; Goldman fusion (i.e., pericarditis, autoimmunity, neo- et al., 2007; Marx et al., 2010). plasm, or trauma; see Table 3). Electrocardiography The ECG typically exhibits reduced voltage IMPLICATIONS FOR PRACTICE and in severe cases . Elec- The patient discussed in this article presented trical alternans is reflective of the heart swing- with upper back and shoulder pain and short- ing anterior and posterior with each heart- ness of breath the day before presenting to beat. When pericarditis is associated with the ED. One sign that alerted the provider to pericardial effusion, ECG findings may be conduct an extensive workup was a heart rate consistent with pericarditis with widespread of 124 beats/min. It is a basic measurement ST elevation, T-wave abnormalities, and PR taken by the triage nurse and can have a great depression (Braunwald et al., 2004; Strimel impact on the course of evaluation, diagnosis, et al., 2009). and treatment by the provider. can be performed di- Tachycardia is easy to overlook. Anxiety agnostically or therapeutically but can have and pain are common upon entrance to the complications of cardiac dysrhythmias, pneu- ED and can induce a mild tachycardia. Abnor- mothorax or perforation of the myocardium, mal vital signs can also be caused by fever, or coronary vasculature. Gross appearance of , pericardial effusion, the pericardial fluid can help differentiate the , and numerous other diag- cause (Marx et al., 2010). noses. Vital signs should always be the first ob- jective sign providers review. They can be the CLINICAL MANAGEMENT difference between a simple and more com- plex workup. Initial management of the patient with peri- It is important for APNs to always review cardial effusion includes volume augmenta- and consider reasons for abnormal vital signs. tion with intravenous fluids, which increases Commonly, patients are sent to the QC area the filling pressure with hopes of overcoming of the ED with “minor”complaints. However, the pericardial constriction. Pericardiocente- we must all be astute to the zebra among the sis is the treatment of choice when imminent horses. or actual pericardial tamponade is present. Serial echocardiograms are recommended to assess the effects of treatment modalities REFERENCES and to evaluate extension of effusion and de- Braunwald, E., Zipes, D. P., Libby, P.,& Bonow, R. (2004). velopment of tamponade (Saito et al., 2008). Pericardial disease. In Braunwalds heart disease text The incidence of pericardial effusion result- of cardiovascular medicine (8th ed.). Retrieved from ing in tamponade has been estimated to be http://www.mdconsult.com/book/player/book.do? LWW/AENJ TME200069 April 26, 2010 11:12 Char Count= 0

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method=display&type=bookPage&decorator=header 940140082#lpState=open&lpTab=contentsTab& &eid=4-u1.0-B978–1-4160–4106-1..50073-X–cesec3& content=4-u1.0-B978–0-323–05472-0..00080–3%3B uniq=178491085&isbn=978–1-4160–4106-1&sid= from%3Dtoc%3Btype%3DbookPage%3Bisbn%3D978– 939901736#lpState=open&lpTab=contentsTab& 0-323–05472-00 content=4-u1.0-B978–1-4160–4106-1..50073-X– Saito, Y., Donohue, A., Attai, S., Vahdat, A., Brar, R., Han- cesec1%3Bfrom%3Dcontent%3Bisbn%3D978–1- dapangoda, I., et al. (2008). The syndrome of cardiac 4160–4106-1%3Btype%3DbookPage tamponade with “small”pericardial effusion. Echocar- Goldman, L., Ausiello, D. A., Arend, W., Armitage, J. O., diography: A Journal of Cardiovascular Ultrasound Clemmons, D., Drazen, J., et al. (2007). Radiology of and Allied Technology, 25(3), 321–327. the heart. In Cecil medicine (23rd ed.). Retrieved Strimel, W. J., Sovari, A. A., Assadi, R., & Kocheril, from http://www.mdconsult.com/das/book/body/ A. G. (2009). Pericardial effusion. Retrieved Jan- 178491085–10/939904529/1492/324.html#4-u1.0- uary 1, 2010, from http://emedicine.medscape.com/ B978–1-4160–2805-5..50082–3–cesec9 3235. article/157325-overview Marx, J., Hockenberger, R., & Walls. (2010). Pericar- Sugiura, T., Kataoka, H., Matsymura, Y., Takeuchi, H., & dial and myocardial disease. In Rosen’s emergency Doi, Y. L. (2009) Asymptomatic pericardial effusion in medicine (7th ed.). Retrieved from http://www.md patients with system lupus erythematosus. Lupus, 18, consult.com/book/player/book.do?method=display& 128–132. type=bookPage&decorator=header&eid=4-u1.0- Wills, C. P., Young, M., & White, D. W. (2010). Pitfalls B978–0-323–05472-0..00080–3–s0030&displayed in the evaluation of shortness of breath. Emergency Eid=4-u1.0-B978–0-323–05472-0..00080–3–s0035& Medicine Clinicians of North America, 28, 163– uniq=178581682&isbn=978–0-323–05472-0&sid= 181. LWW/AENJ AENJ3202-CE April 23, 2010 18:15 Char Count=

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CE TEST QUESTIONS General Purpose Statement: To provide 6. The most common diagnosis asso- 12. An echocardiogram showing dias- professional registered nurses with information ciated with pericardial effusion is tolic collapse starting with the left about pericardial effusions and pericarditis. a. . ventricular wall is characteristic of b. pericarditis. Learning Objectives: After reading the article a. pericarditis. c. pulmonary edema. b. cardiac tamponade. and taking this test, the learner should be able to: d. pulmonary embolism. c. ventricular dysynchrony. 1. Discuss the incidence, pathophysiology, and 7. Chest pain due to pericarditis is d. an isolated left ventricular pericardial effusion. symptoms of pericarditis and pericardial effu- relieved by 13. Computed tomography and sion. a. walking. magnetic resonance imaging 2. Identify diagnostic and imaging tests for peri- b. standing. studies can be used in pericarditis and pericardial effusion. c. lying down. for 3. Describe treatment/management options for d. sitting forward. a. treatment decisions. pericarditis and pericardial effusion. 8. Which statement is true about b. prompt management. 1. Causes of pericardial effusion in- friction rubs? c. first-line diagnostic studies. clude all of the following except a. They consist of three components. d. technically difficult echocardiogram. a. human immunodeficiency virus. b. They are due to late diastolic filling. 14. Electrocardiogram findings in peri- b. malignancy. c. They are heard loudest in a supine position. carditis with pleural effusion would c. hypothyroidism. d. They can best be heard at the right sternal include all except d. . border. a. ST elevation. 2. One third of pericardial effusion 9. Which laboratory study aids in b. PR depression. cases are due to diagnosing pericarditis? c. increased voltage. a. idiopathic inflammation. a. Varicella titre d. T-wave abnormalities. b. trauma/puncture wounds. b. Rheumatoid factor 15. Which complication is least likely c. uremia due to kidney failure. c. Uric acid to result from pericardiocentesis? d. radiation therapy and chemotherapy. d. Spinal fluid analysis a. Pneumothorax 3. Small pericardial effusions are 10. Imaging studies to assist in b. Pulmonary edema usually diagnosing pericarditis include c. Myocardial perforation a. asymptomatic. a. infrared thermography. d. Cardiac dysrhythmias b. intermittently symptomatic. b. electromyography. 16. The treatment of choice for c. more prevalent in Caucasians. c. positron emission tomography. pericardial tamponade is d. fatal in symptomatic patients. d. transesophageal echocardiography. a. insertion. 4. Symptoms of pericardial effusion 11. Cardiomegaly on chest radiograph b. pericardiocentesis. include all of the following except is apparent with a minimum of c. intravenous diuretics. a. cough. a. 50–100 ml of pericardial fluid. d. intravenous fluids to increase cardiac filling b. syncope. b. 100–150 ml of pericardial fluid. pressures. c. hiccups. c. 150–200 ml of pericardial fluid. 17. The annual incidence of pericardial d. orthopnea. d. 200–250 ml of pericardial fluid. effusion resulting in tamponade is 5. Physical assessment of the pa- estimated to be tient with pericardial effusion may a. 3 per 100,000 patients. reveal b. 10 per 100,000 patients. a. . c. 17 per 100,000 patients. b. expiratory wheezing. d. 23 per 100,000 patients. c. poor peripheral pulses. d. an S4 heart sound.

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18. One treatment modality for under- 19. Which aspect of the initial pa- lying pericarditis is tient assessment do the authors a. clonidine. identify as easy to overlook but b. colchicine. can make the difference between c. β-blockers. a simple and more extensive d. antihistamines. workup? a. Family history b. History of presenting symptoms c. Vital signs d. Emergency Severity Index

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