A nurse is assessing a 38-year-old patient admitted with suspected pericarditis. Which assessment finding would be most characteristic of this condition?

Understanding Pericarditis

Pericarditis is an inflammatory condition affecting the pericardium, the double-layered fibroelastic sac surrounding the heart. The underlying pathophysiology involves inflammation of the pericardial layers, which can be triggered by viral infections, autoimmune processes, or cardiac injury. A key concept in contemporary understanding, highlighted in recent literature, is the role of the inflammasome and autoinflammatory pathways, which has led to targeted therapeutics such as anti-interleukin-1 (IL-1) agents ^[1]. This inflammation is the direct cause of the hallmark symptom described in the correct answer.

Analysis of Correct Answer (Option 3)

Sharp chest pain that worsens with inspiration and improves when leaning forward is the most characteristic feature of acute pericarditis. This specific type of pain, termed pleuritic chest pain, occurs because the inflamed, roughened pericardial surfaces rub against each other with each heartbeat and lung movement. During inspiration, the lungs expand and the diaphragm descends, pulling the heart and the inflamed pericardium closer to adjacent structures, which intensifies the friction and pain. Conversely, the leaning forward position reduces pressure on the posterior pericardium and splints the chest wall, thereby minimizing the mechanical irritation and providing characteristic relief. This clinical picture is a cornerstone for diagnosis and guides the initial use of multimodality imaging for confirmation ^[2].

Analysis of Incorrect Options

• Option 1: Bilateral lower extremity edema with jugular venous distention is a classic presentation of right-sided heart failure. In the context of pericardial disease, this finding is not typical of simple acute pericarditis but rather suggests a complication like constrictive pericarditis or a large pericardial effusion causing cardiac tamponade. These conditions impair diastolic filling of the right ventricle, leading to systemic venous congestion. While advanced imaging is vital for differentiating these entities ^[1], they are distinct clinical syndromes from the initial presentation of acute pericarditis.



• Option 2: A harsh systolic murmur heard best at the left sternal border is a hallmark of a ventricular septal defect or significant tricuspid regurgitation. In pericarditis, the characteristic auscultatory finding is a pericardial friction rub, a scratchy, grating sound often heard in systole and diastole, caused by the inflamed pericardial layers moving against each other. A murmur indicates a valvular or structural intracardiac problem, not primary pericardial inflammation.



• Option 4: Crushing substernal chest pain radiating to the left arm and jaw is the classic presentation of an acute myocardial infarction (MI). While pericarditis can occur after an MI as part of post-cardiac injury syndrome (PCIS), this specific pain quality is due to myocardial ischemia, not pericardial inflammation. The recent paradigm shift in understanding PCIS emphasizes that it is a distinct, later-onset inflammatory syndrome, not the initial ischemic event itself . The pain of pericarditis is typically sharp and positional, clearly differentiating it from the pressure-like pain of an MI.

Clinical Reasoning and Diagnostic Approach

When a patient presents with suspected pericarditis, the nurse's assessment findings are critical for early recognition. The presence of pleuritic, positional chest pain should immediately raise suspicion for pericardial inflammation. This clinical suspicion is then supported by diagnostic findings. Echocardiography remains the first-line imaging modality to assess for a pericardial effusion, which can complicate the disease course, and to rule out other pathologies ^[2]. In cases where the diagnosis is uncertain or the patient is at high risk, advanced multimodality imaging, including cardiac magnetic resonance (CMR) or computed tomography (CT), is used to confirm pericardial inflammation and guide targeted therapy [1, 2]. Early recognition of this characteristic pain pattern is essential, as a missed diagnosis can lead to recurrent episodes or, in rare fulminant cases, rapid progression to cardiogenic shock requiring mechanical support .