Physical Examination

General Appearance: Respiratory distress, anxiety, diaphoresis. Dyspnea, pallor, leaning forward position.

Vital Signs: BP, pulse (tachycardia); pulsus paradoxus (drop in systolic BP >10 mmHg with inspiration).

HEENT: Cornea, sclera, iris lesions, oral ulcers (lupus); jugulovenous distention (cardiac tamponade).

Skin: Malar rash (butterfly rash), discoid rash (lupus).

Chest: Crackles (rales), rhonchi.

Heart: Rhythm; friction rub on end-expiration while sitting forward; cardiac rub with 1-3 components at left lower sternal border; distant heart sounds (pericardial effusion).

Rectal: Occult blood.

Extremities: Arthralgias, joint tenderness.

Labs: ECG: diffuse, downwardly, concave, ST segment elevation in limb leads and precordial leads; upright T waves, PR segment depression, low QRS voltage.

Chest X-ray: large cardiac silhouette; "water bottle sign," pericardial calcifications.

Echocardiogram.

Increased WBC; UA, urine protein, urine RBCs; CPK, MB, LDH, blood culture, increased ESR.

Differential Diagnosis: Idiopathic pericarditis, infectious pericarditis (viral, bacterial, mycoplasmal, mycobacterial), Lyme disease, uremia, neoplasm, connective tissue disease, lupus, rheumatic fever, polymyositis, myxedema, sarcoidosis, post myocardial infarction pericarditis (Dressler's syndrome), drugs (penicillin, isoniazid, procainamide, hydralazine).

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