 Welcome back to our MedSmarter question of the week where we're taking a smarter approach to preparing future physicians. Before we get started, if you'll take just a quick minute and click that like button and also subscribe and turn the bell on so that you'll be notified when we post new videos. Let's get right to that question. And as always, we start with the last sentence and then read the rest of the vignette. Which of the following is the most appropriate treatment at this time? A 65 year old female with a long history of poorly controlled type 2 diabetes mellitus and chronic renal failure is admitted to the hospital for treatment of cellulitis. On day 3 of her hospital stay, she complains of chest pain that goes away when she leans forward. An ECG shows diffuse ST segment elevations with PR depressions. Her echocardiogram is normal. Which of the following is the most appropriate treatment at this time? So before we look at the answer choices, let's narrow down some things here. So we've got a patient with poorly controlled type 2 diabetes and chronic renal failure was admitted for cellulitis is having chest pain that goes away when she leans forward. This is important. ECG's got ST segment elevations, PR depressions and echo is normal. That's important. That'll help us rule some things out here. Take a minute. Look at the answer choices. Come up with your answer and put it in the comment box below. So let's go ahead and start off here with option A. Cardiac catheterization. If we were dealing with something that would be some sort of a STEMI or acute coronary syndrome, then this would be our definite go to choice here. But this patient isn't having a risk for ischemic heart disease. Based on these symptoms, I believe she's dealing more with a pericarditis versus any type of acute coronary syndrome. So cardiac catheterization will not be my first choice here. B, dialysis. Dialysis might be a possible answer here. Typically, pericarditis in this setting can be caused by hyperurethemia that can invade the pericardial sac there. So we can remove that uric acid from the blood with dialysis because she does have chronic renal failure. So I'm going to leave that as an option choice. C, NSAIDs, non-steroidal anti-inflammatory drugs. So if we're dealing with pericarditis here that could be viral or idiopathic, then NSAIDs would definitely be an option here that can help us. But since we do have this instance of chronic renal failure, I do think we're dealing more with an issue associated with uric acid rather than something like a viral or idiopathic issue. So therefore we're probably not going to do NSAIDs even though that is a good option for some situations. It's not the best in this situation. So I'm going to rule that out. Pericardia synthesis. We don't see any effusions. The echocardiogram is normal. So I'm going to rule out pericardia synthesis. We don't need that. And E, switch her to another antibiotic regimen. So it said that she did have cellulitis and that's why she was originally admitted. So if we had issues with that antibiotic like anaphylaxis due to an allergic reaction, then definitely we would want to switch her antibiotic. However, not seeing any of that here, antibiotics don't cause uremic acid levels to go up and give us a uremic acid pericarditis. So E is not going to be an answer choice for me, which leaves B as my final answer. And B is the correct answer. So like we said here, this is pericarditis due to uremia. So our uric acid levels are elevated in the blood because they are not being pushed out by the kidneys due to our chronic renal failure. So she has chronic kidney disease causing the pericarditis. So what we need to do is go in and remove that uric acid out of the blood and we do that with our dialysis. Some other things to discuss here. What is the classic presentation of pericarditis? So pleuritic positional chest pain is going to be big for us. So when we say that she leans forward and that chest pain goes away, that's because it's positional. When you are sitting back, that pleurisy, that feeling, that chest pain is going to be there. When you lean forward, that makes it go away. Also, it isn't mentioned in this question, but you will see or actually you will hear a pericardial friction rub on physical exam. It is noteworthy that on an ECG we can see diffuse ST segment elevations, but you need to be able to distinguish that between diffuse elevations and an actual STEMI. So that would be one way that you could confuse a cardiac cath and dialysis here if you believe that we're having problems due to a STEMI. But all of the hints in the question lead us more towards the pericardial problems. So what can cause pericarditis other than what we've discussed here as far as chronic renal failure and uremia? Well, we can also see viruses causing pericarditis. So coxsacchivirus, echovirus, adenovirus, HIV, all of those can give us some pericarditis. We can also see bacteria causing pericarditis. Specific bacteria include tuberculosis, streptococcus pneumoniae, or staph aureus. Sometimes with staph aureus we're talking endocarditis, pneumonia, or postcardiac surgery. It can also be neoplastic, so we could be dealing with cancer. It could be autoimmune, it could be uremic, so which is the situation we're dealing with here. It could be cardiovascular, or it could be idiopathic, meaning we're not for certain what is the cause, but we do know that it is there. And then as this question answers our treatment for this particular type of pericarditis when it's secondary to uremia is going to be dialysis. If you found this material helpful for your studying, please like and consider subscribing to the channel. Also, share this video so that more people can benefit from it like you have.