A 17-year-old boy who is hospitalized for depression on the

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A 17-year-old boy who is hospitalized for depression on the general psychiatric unit complains of severe chest pain. The pain is worse on inspiration and has been present for about 2 weeks. His past medical history is significant for depression with multiple suicide gestures for the past 5 years and seasonal allergies. His only medication is fluoxetine. He tells you that he is not sexually active and denies illicit drug use. Review of systems is significant for a recent bronchitis. Vital signs are temperature 37.2 C (99 F), blood pressure 120/70 mm Hg, pulse 92/min, and respirations 10/min. The patient is disheveled, but well developed. Cardiac examination reveals a leathery sound on systole and diastole. There is a normal rate and rhythm, but no third or fourth heart sounds. The lungs are clear. The lower extremities are normal. An electrocardiogram reveals normal sinus rhythm at a rate of 95/min. Chest x-ray reveals moderate cardiomegaly. A prior report from a chest x-ray taken 8 months ago states that the heart size was normal. The next step in managing this patient would be to

A. begin therapy with ibuprofen
B. begin therapy with prednisone
C. obtain permission for an HIV test
D. order a cardiac perfusion scan
E. send cardiac enzymes to rule out a myocardial infarction

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The answer is A. This patient is presenting with inspiratory chest pain, a leathery rub on systole and diastole, and a newly enlarged heart. This is consistent with postviral pericarditis, the most common form of pericarditis. Treatment includes nonsteroidal antiinflammatory medication and in refractory cases, steroids. Other causes of pericarditis not apropos to this case include myocardial infarction, connective tissue disease such as rheumatoid arthritis and lupus, drugs such as procainamide, hydralazine, and isoniazid, metastatic cancer such as lung and breast cancer, and renal failure.

Steroid treatment such as prednisone (choice B) is prescribed only after an aggressive course of antiinflammatory treatment has failed given the many side effects of steroid medication.

An HIV test (choice C) is unnecessary given the low-risk social history of this patient. Evaluation and treatment for pericarditis is the most appropriate next step.

A cardiac perfusion scan (choice D) would only be appropriate for a postmyocardial infarction. Evaluation and treatment for pericarditis is the most appropriate next step.

Cardiac enzymes (choice E) are unnecessary given the patient's age and lack of electrocardiographic findings to suggest a myocardial infarction. This patient is presenting with inspiratory chest pain, a leathery rub on systole and diastole and a newly enlarged heart. This is consistent with postviral pericarditis, the most common cause of pericarditis.