Pericarditis differential diagnosis: Difference between revisions

Revision as of 04:49, 4 March 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]; Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [3] Homa Najafi, M.D.[4]

Overview

Pericarditis must be differentiated from other causes of chest pain such as myocardial infarction, aortic dissection, and pulmonary embolism.

Differentiating Pericarditis from other Diseases

Pericarditis can be misdiagnosed as myocardial infarction, aortic dissection, pneumonia, or pulmonary embolism and vice versa.

Pericarditis must be differentiated from [differential dx1], [differential dx2], and [differential dx3].

For a full discussion of the differential diagnosis of chest pain click here

For an expert algorithm that aids in the diagnosis of the cause of chest pain click here

These differentiating features are summarized in the table below:^[1]

Characteristic/Parameter	Pericarditis	Myocardial infarction
Pain description	Sharp, pleuritic, retro-sternal (under the sternum) or left precordial (left chest) pain.	Crushing, pressure-like, heavy pain. Described as "elephant on the chest".
Radiation	Pain radiates to the trapezius ridge (to the lowest portion of the scapula on the back) or no radiation.	Pain radiates to the jaw, or the left or arm, or does not radiate.
Exertion	Does not change the pain	Can increase the pain
Position	Pain is worse supine or upon inspiration (breathing in)	Not positional
Onset/duration	Sudden pain, that lasts for hours or sometimes days before a patient comes to the ER	Sudden or chronically worsening pain that can come and go in paroxysms or it can last for hours before the patient decides to come to the ER

Pericarditis also resembles the following disorders and needs to be differentiated from them:

Other differentials

Pericarditis should be differentiated from other diseases presenting with chest pain, shortness of breath and tachypnea. The differentials include the following:^[2]^[3]^[4]^[5]^[6]^[7]^[8]^[9]^[10]^[11]^[12]^[13]^[14]^[15]^[16]^[17]^[18]^[19]^[20]^[21]

Diseases	CT scan and MRI	EKG	Chest X-ray	Tachypnea	Tachycardia	Fever	Chest Pain	Hemoptysis	Dyspnea on Exertion	Wheezing	Chest Tenderness	Nasalopharyngeal Ulceration	Carotid Bruit	Past medical history	Other Findings
Diseases	Diagnostic tests			Physical Examination			Symptoms							Past medical history	Other Findings
Pulmonary embolism	On CT angiography: Intra-luminal filling defect On MRI: Narrowing of involved vessel No contrast seen distal to obstruction Polo-mint sign (partial filling defect surrounded by contrast)	S1Q3T3 pattern representing acute right heart strain	Fleischner sign (enlarged pulmonary artery), Hampton hump, Westermark's sign	✔	✔	✔ (Low grade)	✔	✔ (In case of massive PE)	✔	-	-	-	-	Hypercoagulating conditions (Factor V Leiden, thrombophilia, deep vein thrombosis, immobilization, malignancy, pregnancy)	May be associated with metabolic alkalosis and syncope
Congestive heart failure	On CT scan: Mediastinal lymphadenopathy Hazy mediastinal fat On MRI: Abnormality of cardiac chambers (hypertrophy, dilation) Delayed enhancement MRI may help characterize the myocardial tissue (fibrosis) Late enhancement of contrast in conditions such as myocarditis, sarcoidosis, amyloidosis, Anderson-Fabry's disease, Chagas disease)	Goldberg's criteria may aid in diagnosis of left ventricular dysfunction: (High specificity) SV1 or SV2 + RV5 or RV6 ≥3.5 mV Total QRS amplitude in each of the limb leads ≤0.8 mV R/S ratio <1 in lead V4	Cardiomegaly	✔	✔	✔	-	-	✔	-	-	-	-	Previous myocardial infarction Hypertension (systemic and pulmonary) Cardiac arrythmias Viral infections (myocarditis) Congenital heart defects	Right heart failure associated with: Hepatomegaly Positive hepato-jugular reflex Increased jugular venous pressure Peripheral edema Left heart failure associated with: Pulmonary edema Eventual right heart failure
Percarditis	On contrast enhanced CT scan: Enhancement of the pericardium (due to inflammation) Pericardial effusion Pericardial calcification On gadolinium-enhanced fat-saturated T1-weighted MRI: Pericardial enhancement (due to inflammation) Pericardial effusion	ST elevation PR depression	Large collection of fluid inside the pericardial sac (pericardial effusion) Calcification of pericardial sac	✔	✔	✔ (Low grade)	✔ (Relieved by sitting up and leaning forward)	-	✔	-	-	-	-	Infections: Viral (Coxsackie virus, Herpes virus, Mumps virus, HIV) Bacteria (Mycobacterium tuberculosis-common in developing countries) Fungal (Histoplasmosis) Idiopathic in a large number of cases Autoimmune Uremia Malignancy Previous myocardial infarction	May be clinically classified into: Acute (< 6 weeks) Sub-acute (6 weeks - 6 months) Chronic (> 6 months)
Pneumonia	On CT scan: (not generally indicated) Consolidation (alveolar/lobar pneumonia) Peribronchial nodules (bronchopneumonia) Ground-glass opacity (GGO) Abscess Pleural effusion On MRI: Not indicated	Prolonged PR interval Transient T wave inversions	Consolidation (alveolar/lobar pneumonia) Peribronchial nodules (bronchopneumonia) Ground-glass opacity (GGO)	✔	✔	✔	✔	-	✔	✔	-	-	-	Ill-contact Travelling Smoking Diabetic Recent hospitalization Chronic obstructive pulmonary disease	Requires sputum stain and culture for diagnosis Empiric management usually started before culture results
Vasculitis	On CT scan: (Takayasu arteritis) Vessel wall thickening Luminal narrowing of pulmonary artery Masses or nodules (ANCA-associated granulomatous vasculitis) On MRI: Homogeneous, circumferential vessel wall swelling	Right or left bundle-branch block (Churg-Strauss syndrome) Atrial fibrillation (Churg-Strauss syndrome) Non-specific ST segment and T wave changes	Nodules Cavitation	✔	✔	✔	✔	✔	✔	-	✔	✔	✔	Takayasu arteritis usually found in persons aged 4-60 years with a mean of 30 Giant-cell arteritis usually occurrs in persons aged > 60 years Churg-Strauss syndrome may present with asthma, sinusitis, transient pulmonary infiltrates and neuropathy alongwith cardiac involvement Granulomatous vasculitides may present with nephritis and upper airway (nasopharyngeal) destruction
Chronic obstructive pulmonary disease (COPD)	On CT scan: Chronic bronchitis may show bronchial wall thickening, scarring with bronchovascular irregularity, fibrosis Emphysema may show alveolar septal destruction and airspace enlargement (Centrilobular- upper lobe, panlobular- lower lobe) Giant bubbles On MRI: Increased diameter of pulmonary arteries Peripheral pulmonary vasculature attentuation Loss of retrosternal airspace due to right ventricular enlargement Hyperpolarized Helium MRI may show progressively poor ventilation and destruction of lung	Multifocal atrial tachycardia (atleast 3 distinct P wave morphologies)	Enlarged lung shadows (emphysema) Flattening of diaphragm (emphysema)	✔	✔	-	-	-	✔	✔	-	-	-	Smoking Alpha-1 antitrypsin deficiency Increased sputum production (chronic bronchitis) Cough	Alpha 1 antitrypsin deficiency may be associated with hepatomegaly

References

↑ American College of Physicians (ACP). Medical Knowledge Self-Assessment Program (MKSAP-15): Cardiovascular Medicine. "Pericardial disease." p. 64. ISBN 978-934465-28-8 [1]
↑ Brenes-Salazar JA (2014). "Westermark's and Palla's signs in acute and chronic pulmonary embolism: Still valid in the current computed tomography era". J Emerg Trauma Shock. 7 (1): 57–8. doi:10.4103/0974-2700.125645. PMC 3912657. PMID 24550636.
↑ "CT Angiography of Pulmonary Embolism: Diagnostic Criteria and Causes of Misdiagnosis | RadioGraphics".
↑ Bĕlohlávek J, Dytrych V, Linhart A (2013). "Pulmonary embolism, part I: Epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism". Exp Clin Cardiol. 18 (2): 129–38. PMC 3718593. PMID 23940438.
↑ "Pulmonary Embolism: Symptoms - National Library of Medicine - PubMed Health".
↑ Ramani GV, Uber PA, Mehra MR (2010). "Chronic heart failure: contemporary diagnosis and management". Mayo Clin. Proc. 85 (2): 180–95. doi:10.4065/mcp.2009.0494. PMC 2813829. PMID 20118395.
↑ Blinderman CD, Homel P, Billings JA, Portenoy RK, Tennstedt SL (2008). "Symptom distress and quality of life in patients with advanced congestive heart failure". J Pain Symptom Manage. 35 (6): 594–603. doi:10.1016/j.jpainsymman.2007.06.007. PMC 2662445. PMID 18215495.
↑ Hawkins NM, Petrie MC, Jhund PS, Chalmers GW, Dunn FG, McMurray JJ (2009). "Heart failure and chronic obstructive pulmonary disease: diagnostic pitfalls and epidemiology". Eur. J. Heart Fail. 11 (2): 130–9. doi:10.1093/eurjhf/hfn013. PMC 2639415. PMID 19168510.
↑ Takasugi JE, Godwin JD (1998). "Radiology of chronic obstructive pulmonary disease". Radiol. Clin. North Am. 36 (1): 29–55. PMID 9465867.
↑ Wedzicha JA, Donaldson GC (2003). "Exacerbations of chronic obstructive pulmonary disease". Respir Care. 48 (12): 1204–13, discussion 1213–5. PMID 14651761.
↑ Nakawah MO, Hawkins C, Barbandi F (2013). "Asthma, chronic obstructive pulmonary disease (COPD), and the overlap syndrome". J Am Board Fam Med. 26 (4): 470–7. doi:10.3122/jabfm.2013.04.120256. PMID 23833163.
↑ Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK (2010). "Pericardial disease: diagnosis and management". Mayo Clin. Proc. 85 (6): 572–93. doi:10.4065/mcp.2010.0046. PMC 2878263. PMID 20511488.
↑ Bogaert J, Francone M (2013). "Pericardial disease: value of CT and MR imaging". Radiology. 267 (2): 340–56. doi:10.1148/radiol.13121059. PMID 23610095.
↑ Gharib AM, Stern EJ (2001). "Radiology of pneumonia". Med. Clin. North Am. 85 (6): 1461–91, x. PMID 11680112.
↑ Schmidt WA (2013). "Imaging in vasculitis". Best Pract Res Clin Rheumatol. 27 (1): 107–18. doi:10.1016/j.berh.2013.01.001. PMID 23507061.
↑ Suresh E (2006). "Diagnostic approach to patients with suspected vasculitis". Postgrad Med J. 82 (970): 483–8. doi:10.1136/pgmj.2005.042648. PMC 2585712. PMID 16891436.
↑ Stein PD, Dalen JE, McIntyre KM, Sasahara AA, Wenger NK, Willis PW (1975). "The electrocardiogram in acute pulmonary embolism". Prog Cardiovasc Dis. 17 (4): 247–57. PMID 123074.
↑ Warnier MJ, Rutten FH, Numans ME, Kors JA, Tan HL, de Boer A, Hoes AW, De Bruin ML (2013). "Electrocardiographic characteristics of patients with chronic obstructive pulmonary disease". COPD. 10 (1): 62–71. doi:10.3109/15412555.2012.727918. PMID 23413894.
↑ Stein PD, Matta F, Ekkah M, Saleh T, Janjua M, Patel YR, Khadra H (2012). "Electrocardiogram in pneumonia". Am. J. Cardiol. 110 (12): 1836–40. doi:10.1016/j.amjcard.2012.08.019. PMID 23000104.
↑ Hazebroek MR, Kemna MJ, Schalla S, Sanders-van Wijk S, Gerretsen SC, Dennert R, Merken J, Kuznetsova T, Staessen JA, Brunner-La Rocca HP, van Paassen P, Cohen Tervaert JW, Heymans S (2015). "Prevalence and prognostic relevance of cardiac involvement in ANCA-associated vasculitis: eosinophilic granulomatosis with polyangiitis and granulomatosis with polyangiitis". Int. J. Cardiol. 199: 170–9. doi:10.1016/j.ijcard.2015.06.087. PMID 26209947.
↑ Dennert RM, van Paassen P, Schalla S, Kuznetsova T, Alzand BS, Staessen JA, Velthuis S, Crijns HJ, Tervaert JW, Heymans S (2010). "Cardiac involvement in Churg-Strauss syndrome". Arthritis Rheum. 62 (2): 627–34. doi:10.1002/art.27263. PMID 20112390.

Template:WH Template:WS

[mk-1] American College of Physicians (ACP). Medical Knowledge Self-Assessment Program (MKSAP-15): Cardiovascular Medicine. "Pericardial disease." p. 64. ISBN 978-934465-28-8 [1]

[pmid24550636-2] Brenes-Salazar JA (2014). "Westermark's and Palla's signs in acute and chronic pulmonary embolism: Still valid in the current computed tomography era". J Emerg Trauma Shock. 7 (1): 57–8. doi:10.4103/0974-2700.125645. PMC 3912657. PMID 24550636.

[urlCT_Angiography_of_Pulmonary_Embolism:_Diagnostic_Criteria_and_Causes_of_Misdiagnosis_|_RadioGraphics-3] "CT Angiography of Pulmonary Embolism: Diagnostic Criteria and Causes of Misdiagnosis | RadioGraphics".

[pmid23940438-4] Bĕlohlávek J, Dytrych V, Linhart A (2013). "Pulmonary embolism, part I: Epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism". Exp Clin Cardiol. 18 (2): 129–38. PMC 3718593. PMID 23940438.

[urlPulmonary_Embolism:_Symptoms_-_National_Library_of_Medicine_-_PubMed_Health-5] "Pulmonary Embolism: Symptoms - National Library of Medicine - PubMed Health".

[pmid20118395-6] Ramani GV, Uber PA, Mehra MR (2010). "Chronic heart failure: contemporary diagnosis and management". Mayo Clin. Proc. 85 (2): 180–95. doi:10.4065/mcp.2009.0494. PMC 2813829. PMID 20118395.

[pmid18215495-7] Blinderman CD, Homel P, Billings JA, Portenoy RK, Tennstedt SL (2008). "Symptom distress and quality of life in patients with advanced congestive heart failure". J Pain Symptom Manage. 35 (6): 594–603. doi:10.1016/j.jpainsymman.2007.06.007. PMC 2662445. PMID 18215495.

[pmid19168510-8] Hawkins NM, Petrie MC, Jhund PS, Chalmers GW, Dunn FG, McMurray JJ (2009). "Heart failure and chronic obstructive pulmonary disease: diagnostic pitfalls and epidemiology". Eur. J. Heart Fail. 11 (2): 130–9. doi:10.1093/eurjhf/hfn013. PMC 2639415. PMID 19168510.

[pmid9465867-9] Takasugi JE, Godwin JD (1998). "Radiology of chronic obstructive pulmonary disease". Radiol. Clin. North Am. 36 (1): 29–55. PMID 9465867.

[pmid14651761-10] Wedzicha JA, Donaldson GC (2003). "Exacerbations of chronic obstructive pulmonary disease". Respir Care. 48 (12): 1204–13, discussion 1213–5. PMID 14651761.

[pmid23833163-11] Nakawah MO, Hawkins C, Barbandi F (2013). "Asthma, chronic obstructive pulmonary disease (COPD), and the overlap syndrome". J Am Board Fam Med. 26 (4): 470–7. doi:10.3122/jabfm.2013.04.120256. PMID 23833163.

[pmid20511488-12] Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK (2010). "Pericardial disease: diagnosis and management". Mayo Clin. Proc. 85 (6): 572–93. doi:10.4065/mcp.2010.0046. PMC 2878263. PMID 20511488.

[pmid23610095-13] Bogaert J, Francone M (2013). "Pericardial disease: value of CT and MR imaging". Radiology. 267 (2): 340–56. doi:10.1148/radiol.13121059. PMID 23610095.

[pmid11680112-14] Gharib AM, Stern EJ (2001). "Radiology of pneumonia". Med. Clin. North Am. 85 (6): 1461–91, x. PMID 11680112.

[pmid23507061-15] Schmidt WA (2013). "Imaging in vasculitis". Best Pract Res Clin Rheumatol. 27 (1): 107–18. doi:10.1016/j.berh.2013.01.001. PMID 23507061.

[pmid16891436-16] Suresh E (2006). "Diagnostic approach to patients with suspected vasculitis". Postgrad Med J. 82 (970): 483–8. doi:10.1136/pgmj.2005.042648. PMC 2585712. PMID 16891436.

[pmid123074-17] Stein PD, Dalen JE, McIntyre KM, Sasahara AA, Wenger NK, Willis PW (1975). "The electrocardiogram in acute pulmonary embolism". Prog Cardiovasc Dis. 17 (4): 247–57. PMID 123074.

[pmid23413894-18] Warnier MJ, Rutten FH, Numans ME, Kors JA, Tan HL, de Boer A, Hoes AW, De Bruin ML (2013). "Electrocardiographic characteristics of patients with chronic obstructive pulmonary disease". COPD. 10 (1): 62–71. doi:10.3109/15412555.2012.727918. PMID 23413894.

[pmid23000104-19] Stein PD, Matta F, Ekkah M, Saleh T, Janjua M, Patel YR, Khadra H (2012). "Electrocardiogram in pneumonia". Am. J. Cardiol. 110 (12): 1836–40. doi:10.1016/j.amjcard.2012.08.019. PMID 23000104.

[pmid26209947-20] Hazebroek MR, Kemna MJ, Schalla S, Sanders-van Wijk S, Gerretsen SC, Dennert R, Merken J, Kuznetsova T, Staessen JA, Brunner-La Rocca HP, van Paassen P, Cohen Tervaert JW, Heymans S (2015). "Prevalence and prognostic relevance of cardiac involvement in ANCA-associated vasculitis: eosinophilic granulomatosis with polyangiitis and granulomatosis with polyangiitis". Int. J. Cardiol. 199: 170–9. doi:10.1016/j.ijcard.2015.06.087. PMID 26209947.

[pmid20112390-21] Dennert RM, van Paassen P, Schalla S, Kuznetsova T, Alzand BS, Staessen JA, Velthuis S, Crijns HJ, Tervaert JW, Heymans S (2010). "Cardiac involvement in Churg-Strauss syndrome". Arthritis Rheum. 62 (2): 627–34. doi:10.1002/art.27263. PMID 20112390.

[1]

[2]

[3]

[4]

[5]

[6]

[7]

[8]

[9]

[10]

[11]

[12]

[13]

[14]

[15]

[16]

[17]

[18]

[19]

[20]

[21]

@@ Line 9: / Line 9: @@
 ==Differentiating Pericarditis from other Diseases==
 Pericarditis can be misdiagnosed as [[myocardial infarction]], [[aortic dissection]], [[pneumonia]], or [[pulmonary embolism]] and vice versa.
+Pericarditis must be differentiated from [differential dx1], [differential dx2], and [differential dx3].
 '''For a full discussion of the differential diagnosis of [[chest pain]] click [[chest pain|here]]'''
@@ Line 14: / Line 16: @@
 '''For an expert algorithm that aids in the diagnosis of the cause of [[chest pain]] click [[chest pain|here]]'''
-Although the following features are not 100% sensitive and/or specific in distinguishing the different causes of [[chest pain]], they are useful guides:
+These differentiating features are summarized in the table below:<ref name="mk">American College of Physicians (ACP). Medical Knowledge Self-Assessment Program (MKSAP-15): Cardiovascular Medicine. "Pericardial disease." p. 64. ISBN 978-934465-28-8 [http://www.acponline.org/products_services/mksap/15/complete.htm]</ref>
-*[[Pain]] along the trapezius ridge(s), is very characteristic of pericarditis. The pain of [[myocardial infarction]] tends to involve the anterior [[precordium]] with either no radiation or radiation to either the jaw or the left arm.
-*Unlike cardiac [[ischemia]], the pain of pericarditis often lasts longer, and is unresponsive to [[vasodilator]] therapy.
-*Ischemic [[chest pain]] is often described as a sense of "heaviness", "vice like", "pressure like", or like "an elephant sitting on the chest". The pain of pericarditis is often sharp and [[pleuritic]] (exacerbated by breathing in).
-*Ischemic [[chest pain]] is generally not positional in nature whereas the pain of pericarditis is relieved by sitting up and bending forward and worsened by lying down (recumbent or [[supine]] position) or inspiration (taking a breath in).<ref name=mk>American College of Physicians (ACP). Medical Knowledge Self-Assessment Program (MKSAP-15): Cardiovascular Medicine. "Pericardial disease." p. 64. ISBN 978-934465-28-8 [http://www.acponline.org/products_services/mksap/15/complete.htm]</ref>
-*The [[EKG]] of pericarditis shows [[PR]] segment depression while the EKG of [[myocardial infarction]] does not (unless there is atrial infarction).
-*The [[EKG]] of pericarditis shows [[ST elevation]] that does not necessarily follow the anatomic distribution of a single [[coronary artery]].
-*Other symptoms of pericarditis may include a viral prodrome including dry [[cough]], [[fever]], and [[fatigue]].
-These differentiating features are summarized in the table below:<ref name=mk />
 {| class="wikitable"
 ! scope="col" | Characteristic/Parameter
@@ Line 60: / Line 53: @@
 *[[Gastroesophageal reflux disease]]
 *[[Peptic ulcer disease]]
-==Chest Pain Following Myocardial Infarction ==
-It should be noted that [[ST elevation MI]] can also be associated with the subsequent development of pericarditis. In a patient with recurrent [[chest pain]] following [[acute MI]], one is often left wondering whether the [[chest pain]] is due to [[reocclusion]] of the culprit artery, or if it is due to the early development of [[pericarditis]], or if it occurs later, if it is due to [[Dressler's syndrome]].  Occlusion of the culprit artery or [[stent thrombosis]] should be associated with recurrent [[ST segment]] elevation in the appropriate anatomic [[ECG]] leads.
-==Diagnosing Tuberculous Pericarditis: The Tygerberg Scoring System==
-Pericarditis caused by [[tuberculosis]] is difficult to diagnose, because definitive diagnosis requires culturing ''[[Mycobacterium tuberculosis]]'' from aspirated [[pericardium|pericardial]] fluid or pericardial [[Wiktionary:biopsy|biopsy]], which requires high technical skill and is often not diagnostic (the yield from culture is low even with optimum specimens).
-The [[Tygerberg score|Tygerberg scoring system]] is useful in ascertaining if pericarditis is due to tuberculosis.  In order to calculate the score, the points are added together:
-* [[Night sweats]] (1 point),
-* [[Weight loss]] (1 point),
-* [[Fever]] (2 point),
-* Serum [[globulin]] &gt; 40g/L (3 points),
-* Blood total [[leukocyte]] count &lt; 10 x 10<sup>9</sup>/L (3 points)
-A total score of 6 or more is highly suggestive of [[tuberculous pericarditis]].<ref>{{cite journal | author=Reuter H, Burgess L, van Vuuren W, Doubell A. | title=Diagnosing tuberculous pericarditis | journal=Q J Med | year=2006 | volume=99 | pages=827&ndash;39 | pmid=17121764 }}</ref>
-Pericardial fluid with an [[interferon-gamma|interferon-γ]] level greater than 50 [[Wiktionary:picogram|pg]]/mL is highly specific for [[tuberculous pericarditis]].
 ==Other differentials==
-Pericarditis should be differentiated from other diseases presenting with [[chest pain]], [[shortness of breath]] and [[tachypnea]]. The differentials include the following:<ref name="pmid24550636">{{cite journal |vauthors=Brenes-Salazar JA |title=Westermark's and Palla's signs in acute and chronic pulmonary embolism: Still valid in the current computed tomography era |journal=J Emerg Trauma Shock |volume=7 |issue=1 |pages=57–8 |year=2014 |pmid=24550636 |pmc=3912657 |doi=10.4103/0974-2700.125645 |url=}}</ref><ref name="urlCT Angiography of Pulmonary Embolism: Diagnostic Criteria and Causes of Misdiagnosis | RadioGraphics">{{cite web |url=http://pubs.rsna.org/doi/full/10.1148/rg.245045008 |title=CT Angiography of Pulmonary Embolism: Diagnostic Criteria and Causes of Misdiagnosis &#124; RadioGraphics |format= |work= |accessdate=}}</ref><ref name="pmid23940438">{{cite journal |vauthors=Bĕlohlávek J, Dytrych V, Linhart A |title=Pulmonary embolism, part I: Epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism |journal=Exp Clin Cardiol |volume=18 |issue=2 |pages=129–38 |year=2013 |pmid=23940438 |pmc=3718593 |doi= |url=}}</ref><ref name="urlPulmonary Embolism: Symptoms - National Library of Medicine - PubMed Health">{{cite web |url=https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0022657/ |title=Pulmonary Embolism: Symptoms - National Library of Medicine - PubMed Health |format= |work= |accessdate=}}</ref><ref name="pmid20118395">{{cite journal |vauthors=Ramani GV, Uber PA, Mehra MR |title=Chronic heart failure: contemporary diagnosis and management |journal=Mayo Clin. Proc. |volume=85 |issue=2 |pages=180–95 |year=2010 |pmid=20118395 |pmc=2813829 |doi=10.4065/mcp.2009.0494 |url=}}</ref><ref name="pmid18215495">{{cite journal |vauthors=Blinderman CD, Homel P, Billings JA, Portenoy RK, Tennstedt SL |title=Symptom distress and quality of life in patients with advanced congestive heart failure |journal=J Pain Symptom Manage |volume=35 |issue=6 |pages=594–603 |year=2008 |pmid=18215495 |pmc=2662445 |doi=10.1016/j.jpainsymman.2007.06.007 |url=}}</ref><ref name="pmid19168510">{{cite journal |vauthors=Hawkins NM, Petrie MC, Jhund PS, Chalmers GW, Dunn FG, McMurray JJ |title=Heart failure and chronic obstructive pulmonary disease: diagnostic pitfalls and epidemiology |journal=Eur. J. Heart Fail. |volume=11 |issue=2 |pages=130–9 |year=2009 |pmid=19168510 |pmc=2639415 |doi=10.1093/eurjhf/hfn013 |url=}}</ref><ref name="pmid9465867">{{cite journal |vauthors=Takasugi JE, Godwin JD |title=Radiology of chronic obstructive pulmonary disease |journal=Radiol. Clin. North Am. |volume=36 |issue=1 |pages=29–55 |year=1998 |pmid=9465867 |doi= |url=}}</ref><ref name="pmid14651761">{{cite journal |vauthors=Wedzicha JA, Donaldson GC |title=Exacerbations of chronic obstructive pulmonary disease |journal=Respir Care |volume=48 |issue=12 |pages=1204–13; discussion 1213–5 |year=2003 |pmid=14651761 |doi= |url=}}</ref><ref name="pmid23833163">{{cite journal |vauthors=Nakawah MO, Hawkins C, Barbandi F |title=Asthma, chronic obstructive pulmonary disease (COPD), and the overlap syndrome |journal=J Am Board Fam Med |volume=26 |issue=4 |pages=470–7 |year=2013 |pmid=23833163 |doi=10.3122/jabfm.2013.04.120256 |url=}}</ref><ref name="pmid20511488">{{cite journal |vauthors=Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK |title=Pericardial disease: diagnosis and management |journal=Mayo Clin. Proc. |volume=85 |issue=6 |pages=572–93 |year=2010 |pmid=20511488 |pmc=2878263 |doi=10.4065/mcp.2010.0046 |url=}}</ref><ref name="pmid23610095">{{cite journal |vauthors=Bogaert J, Francone M |title=Pericardial disease: value of CT and MR imaging |journal=Radiology |volume=267 |issue=2 |pages=340–56 |year=2013 |pmid=23610095 |doi=10.1148/radiol.13121059 |url=}}</ref><ref name="pmid11680112">{{cite journal |vauthors=Gharib AM, Stern EJ |title=Radiology of pneumonia |journal=Med. Clin. North Am. |volume=85 |issue=6 |pages=1461–91, x |year=2001 |pmid=11680112 |doi= |url=}}</ref><ref name="pmid23507061">{{cite journal |vauthors=Schmidt WA |title=Imaging in vasculitis |journal=Best Pract Res Clin Rheumatol |volume=27 |issue=1 |pages=107–18 |year=2013 |pmid=23507061 |doi=10.1016/j.berh.2013.01.001 |url=}}</ref><ref name="pmid16891436">{{cite journal |vauthors=Suresh E |title=Diagnostic approach to patients with suspected vasculitis |journal=Postgrad Med J |volume=82 |issue=970 |pages=483–8 |year=2006 |pmid=16891436 |pmc=2585712 |doi=10.1136/pgmj.2005.042648 |url=}}</ref><ref name="pmid123074">{{cite journal |vauthors=Stein PD, Dalen JE, McIntyre KM, Sasahara AA, Wenger NK, Willis PW |title=The electrocardiogram in acute pulmonary embolism |journal=Prog Cardiovasc Dis |volume=17 |issue=4 |pages=247–57 |year=1975 |pmid=123074 |doi= |url=}}</ref><ref name="pmid23413894">{{cite journal |vauthors=Warnier MJ, Rutten FH, Numans ME, Kors JA, Tan HL, de Boer A, Hoes AW, De Bruin ML |title=Electrocardiographic characteristics of patients with chronic obstructive pulmonary disease |journal=COPD |volume=10 |issue=1 |pages=62–71 |year=2013 |pmid=23413894 |doi=10.3109/15412555.2012.727918 |url=}}</ref><ref name="pmid23000104">{{cite journal |vauthors=Stein PD, Matta F, Ekkah M, Saleh T, Janjua M, Patel YR, Khadra H |title=Electrocardiogram in pneumonia |journal=Am. J. Cardiol. |volume=110 |issue=12 |pages=1836–40 |year=2012 |pmid=23000104 |doi=10.1016/j.amjcard.2012.08.019 |url=}}</ref><ref name="pmid26209947">{{cite journal |vauthors=Hazebroek MR, Kemna MJ, Schalla S, Sanders-van Wijk S, Gerretsen SC, Dennert R, Merken J, Kuznetsova T, Staessen JA, Brunner-La Rocca HP, van Paassen P, Cohen Tervaert JW, Heymans S |title=Prevalence and prognostic relevance of cardiac involvement in ANCA-associated vasculitis: eosinophilic granulomatosis with polyangiitis and granulomatosis with polyangiitis |journal=Int. J. Cardiol. |volume=199 |issue= |pages=170–9 |year=2015 |pmid=26209947 |doi=10.1016/j.ijcard.2015.06.087 |url=}}</ref><ref name="pmid20112390">{{cite journal |vauthors=Dennert RM, van Paassen P, Schalla S, Kuznetsova T, Alzand BS, Staessen JA, Velthuis S, Crijns HJ, Tervaert JW, Heymans S |title=Cardiac involvement in Churg-Strauss syndrome |journal=Arthritis Rheum. |volume=62 |issue=2 |pages=627–34 |year=2010 |pmid=20112390 |doi=10.1002/art.27263 |url=}}</ref>
+Pericarditis should be differentiated from other diseases presenting with [[chest pain]], [[shortness of breath]] and [[tachypnea]]. The differentials include the following:<ref name="pmid24550636">{{cite journal |vauthors=Brenes-Salazar JA |title=Westermark's and Palla's signs in acute and chronic pulmonary embolism: Still valid in the current computed tomography era |journal=J Emerg Trauma Shock |volume=7 |issue=1 |pages=57–8 |year=2014 |pmid=24550636 |pmc=3912657 |doi=10.4103/0974-2700.125645 |url=}}</ref><ref name="urlCT Angiography of Pulmonary Embolism: Diagnostic Criteria and Causes of Misdiagnosis | RadioGraphics">{{cite web |url=http://pubs.rsna.org/doi/full/10.1148/rg.245045008 |title=CT Angiography of Pulmonary Embolism: Diagnostic Criteria and Causes of Misdiagnosis &#124; RadioGraphics |format= |work= |accessdate=}}</ref><ref name="pmid23940438">{{cite journal |vauthors=Bĕlohlávek J, Dytrych V, Linhart A |title=Pulmonary embolism, part I: Epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism |journal=Exp Clin Cardiol |volume=18 |issue=2 |pages=129–38 |year=2013 |pmid=23940438 |pmc=3718593 |doi= |url=}}</ref><ref name="urlPulmonary Embolism: Symptoms - National Library of Medicine - PubMed Health">{{cite web |url=https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0022657/ |title=Pulmonary Embolism: Symptoms - National Library of Medicine - PubMed Health |format= |work= |accessdate=}}</ref><ref name="pmid20118395">{{cite journal |vauthors=Ramani GV, Uber PA, Mehra MR |title=Chronic heart failure: contemporary diagnosis and management |journal=Mayo Clin. Proc. |volume=85 |issue=2 |pages=180–95 |year=2010 |pmid=20118395 |pmc=2813829 |doi=10.4065/mcp.2009.0494 |url=}}</ref><ref name="pmid18215495">{{cite journal |vauthors=Blinderman CD, Homel P, Billings JA, Portenoy RK, Tennstedt SL |title=Symptom distress and quality of life in patients with advanced congestive heart failure |journal=J Pain Symptom Manage |volume=35 |issue=6 |pages=594–603 |year=2008 |pmid=18215495 |pmc=2662445 |doi=10.1016/j.jpainsymman.2007.06.007 |url=}}</ref><ref name="pmid19168510">{{cite journal |vauthors=Hawkins NM, Petrie MC, Jhund PS, Chalmers GW, Dunn FG, McMurray JJ |title=Heart failure and chronic obstructive pulmonary disease: diagnostic pitfalls and epidemiology |journal=Eur. J. Heart Fail. |volume=11 |issue=2 |pages=130–9 |year=2009 |pmid=19168510 |pmc=2639415 |doi=10.1093/eurjhf/hfn013 |url=}}</ref><ref name="pmid9465867">{{cite journal |vauthors=Takasugi JE, Godwin JD |title=Radiology of chronic obstructive pulmonary disease |journal=Radiol. Clin. North Am. |volume=36 |issue=1 |pages=29–55 |year=1998 |pmid=9465867 |doi= |url=}}</ref><ref name="pmid14651761">{{cite journal |vauthors=Wedzicha JA, Donaldson GC |title=Exacerbations of chronic obstructive pulmonary disease |journal=Respir Care |volume=48 |issue=12 |pages=1204–13; discussion 1213–5 |year=2003 |pmid=14651761 |doi= |url=}}</ref><ref name="pmid23833163">{{cite journal |vauthors=Nakawah MO, Hawkins C, Barbandi F |title=Asthma, chronic obstructive pulmonary disease (COPD), and the overlap syndrome |journal=J Am Board Fam Med |volume=26 |issue=4 |pages=470–7 |year=2013 |pmid=23833163 |doi=10.3122/jabfm.2013.04.120256 |url=}}</ref><ref name="pmid20511488">{{cite journal |vauthors=Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK |title=Pericardial disease: diagnosis and management |journal=Mayo Clin. Proc. |volume=85 |issue=6 |pages=572–93 |year=2010 |pmid=20511488 |pmc=2878263 |doi=10.4065/mcp.2010.0046 |url=}}</ref><ref name="pmid23610095">{{cite journal |vauthors=Bogaert J, Francone M |title=Pericardial disease: value of CT and MR imaging |journal=Radiology |volume=267 |issue=2 |pages=340–56 |year=2013 |pmid=23610095 |doi=10.1148/radiol.13121059 |url=}}</ref><ref name="pmid11680112">{{cite journal |vauthors=Gharib AM, Stern EJ |title=Radiology of pneumonia |journal=Med. Clin. North Am. |volume=85 |issue=6 |pages=1461–91, x |year=2001 |pmid=11680112 |doi= |url=}}</ref><ref name="pmid23507061">{{cite journal |vauthors=Schmidt WA |title=Imaging in vasculitis |journal=Best Pract Res Clin Rheumatol |volume=27 |issue=1 |pages=107–18 |year=2013 |pmid=23507061 |doi=10.1016/j.berh.2013.01.001 |url=}}</ref><ref name="pmid16891436">{{cite journal |vauthors=Suresh E |title=Diagnostic approach to patients with suspected vasculitis |journal=Postgrad Med J |volume=82 |issue=970 |pages=483–8 |year=2006 |pmid=16891436 |pmc=2585712 |doi=10.1136/pgmj.2005.042648 |url=}}</ref><ref name="pmid123074">{{cite journal |vauthors=Stein PD, Dalen JE, McIntyre KM, Sasahara AA, Wenger NK, Willis PW |title=The electrocardiogram in acute pulmonary embolism |journal=Prog Cardiovasc Dis |volume=17 |issue=4 |pages=247–57 |year=1975 |pmid=123074 |doi= |url=}}</ref><ref name="pmid23413894">{{cite journal |vauthors=Warnier MJ, Rutten FH, Numans ME, Kors JA, Tan HL, de Boer A, Hoes AW, De Bruin ML |title=Electrocardiographic characteristics of patients with chronic obstructive pulmonary disease |journal=COPD |volume=10 |issue=1 |pages=62–71 |year=2013 |pmid=23413894 |doi=10.3109/15412555.2012.727918 |url=}}</ref><ref name="pmid23000104">{{cite journal |vauthors=Stein PD, Matta F, Ekkah M, Saleh T, Janjua M, Patel YR, Khadra H |title=Electrocardiogram in pneumonia |journal=Am. J. Cardiol. |volume=110 |issue=12 |pages=1836–40 |year=2012 |pmid=23000104 |doi=10.1016/j.amjcard.2012.08.019 |url=}}</ref><ref name="pmid26209947">{{cite journal |vauthors=Hazebroek MR, Kemna MJ, Schalla S, Sanders-van Wijk S, Gerretsen SC, Dennert R, Merken J, Kuznetsova T, Staessen JA, Brunner-La Rocca HP, van Paassen P, Cohen Tervaert JW, Heymans S |title=Prevalence and prognostic relevance of cardiac involvement in ANCA-associated vasculitis: eosinophilic granulomatosis with polyangiitis and granulomatosis with polyangiitis |journal=Int. J. Cardiol. |volume=199 |issue= |pages=170–9 |year=2015 |pmid=26209947 |doi=10.1016/j.ijcard.2015.06.087 |url=}}</ref><ref name="pmid20112390">{{cite journal |vauthors=Dennert RM, van Paassen P, Schalla S, Kuznetsova T, Alzand BS, Staessen JA, Velthuis S, Crijns HJ, Tervaert JW, Heymans S |title=Cardiac involvement in Churg-Strauss syndrome |journal=Arthritis Rheum. |volume=62 |issue=2 |pages=627–34 |year=2010 |pmid=20112390 |doi=10.1002/art.27263 |url=}}</ref><small>
-<small>
 {|
 |- style="background: #4479BA; color: #FFFFFF; text-align: center;"
@@ Line 90: / Line 65: @@
 ! rowspan="2" |<small>Other Findings</small>
 |- style="background: #4479BA; color: #FFFFFF; text-align: center;"
 !<small>CT scan and MRI</small>
 !<small>EKG</small>
 !<small>Chest X-ray</small>
 !<small>Tachypnea</small>
 !<small>Tachycardia</small>
@@ Line 105: / Line 80: @@
 |-
 | style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Pulmonary embolism]]
-| style="background: #F5F5F5; padding: 5px;"|
+| style="background: #F5F5F5; padding: 5px;" |
 *On [[CT angiography]]:
 ** Intra-luminal filling defect
 *On [[MRI]]:
 ** Narrowing of involved [[Blood vessel|vessel]]
@@ Line 113: / Line 88: @@
 ** Polo-mint sign (partial filling defect surrounded by contrast)
 | style="background: #F5F5F5; padding: 5px;" |
-* [[Pulmonary embolism electrocardiogram|S1Q3T3]] pattern representing acute [[right heart]] strain
+*[[Pulmonary embolism electrocardiogram|S1Q3T3]] pattern representing acute [[right heart]] strain
 | style="background: #F5F5F5; padding: 5px;" |
-* [[Fleischner sign]] (enlarged pulmonary artery), [[Hampton's hump|Hampton hump]], [[Westermark's sign]]
+*[[Fleischner sign]] (enlarged pulmonary artery), [[Hampton's hump|Hampton hump]], [[Westermark's sign]]
 | style="background: #F5F5F5; padding: 5px;" |✔
 | style="background: #F5F5F5; padding: 5px;" |✔
@@ Line 122: / Line 97: @@
 | style="background: #F5F5F5; padding: 5px;" |✔ (In case of massive PE)
 | style="background: #F5F5F5; padding: 5px;" |✔
-| style="background: #F5F5F5; padding: 5px;" | -
+| style="background: #F5F5F5; padding: 5px;" |  -
-| style="background: #F5F5F5; padding: 5px;" | -
+| style="background: #F5F5F5; padding: 5px;" |  -
-| style="background: #F5F5F5; padding: 5px;" | -
+| style="background: #F5F5F5; padding: 5px;" |  -
-| style="background: #F5F5F5; padding: 5px;" | -
+| style="background: #F5F5F5; padding: 5px;" |  -
 | style="background: #F5F5F5; padding: 5px;" |
 *Hypercoagulating conditions ([[Factor V Leiden]], [[thrombophilia]], [[deep vein thrombosis]], immobilization, [[malignancy]], [[pregnancy]])
@@ Line 131: / Line 106: @@
 * May be associated with [[metabolic alkalosis]] and [[syncope]]
 |-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" | [[Congestive heart failure]]
+| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Congestive heart failure]]
 | style="background: #F5F5F5; padding: 5px;" |
 *On [[Computed tomography|CT scan]]:
-** [[Mediastinal lymphadenopathy]]
+**[[Mediastinal lymphadenopathy]]
 ** Hazy [[mediastinal]] fat
 *On [[Magnetic resonance imaging|MRI]]:
@@ Line 144: / Line 119: @@
 **[[S wave|S]]V1 or [[S wave|S]]V2 + [[R wave|R]]V5 or [[R wave|R]]V6 ≥3.5 mV
 **Total [[QRS complex|QRS]] amplitude in each of the limb leads ≤0.8 mV
-** [[R wave|R]]/[[S wave|S]] ratio <1 in lead V4
+**[[R wave|R]]/[[S wave|S]] ratio <1 in lead V4
 | style="background: #F5F5F5; padding: 5px;" |
 *[[Cardiomegaly]]
@@ Line 150: / Line 125: @@
 | style="background: #F5F5F5; padding: 5px;" |✔
 | style="background: #F5F5F5; padding: 5px;" |✔
-| style="background: #F5F5F5; padding: 5px;" | -
+| style="background: #F5F5F5; padding: 5px;" |  -
-| style="background: #F5F5F5; padding: 5px;" | -
+| style="background: #F5F5F5; padding: 5px;" |  -
 | style="background: #F5F5F5; padding: 5px;" |✔
-| style="background: #F5F5F5; padding: 5px;" | -
+| style="background: #F5F5F5; padding: 5px;" |  -
-| style="background: #F5F5F5; padding: 5px;" | -
+| style="background: #F5F5F5; padding: 5px;" |  -
-| style="background: #F5F5F5; padding: 5px;" | -
+| style="background: #F5F5F5; padding: 5px;" |  -
-| style="background: #F5F5F5; padding: 5px;" | -
+| style="background: #F5F5F5; padding: 5px;" |  -
 | style="background: #F5F5F5; padding: 5px;" |
 *Previous [[myocardial infarction]]
@@ Line 165: / Line 140: @@
 | style="background: #F5F5F5; padding: 5px;" |
 *[[Right heart failure]] associated with:
 **[[Hepatomegaly]]
 **Positive hepato-jugular reflex
 **Increased [[jugular venous pressure]]
 **[[Peripheral edema]]
 *[[Left heart failure]] associated with:
 **[[Pulmonary edema]]
@@ Line 192: / Line 167: @@
 | style="background: #F5F5F5; padding: 5px;" |✔ (Low grade)
 | style="background: #F5F5F5; padding: 5px;" |✔ (Relieved by sitting up and leaning forward)
-| style="background: #F5F5F5; padding: 5px;" | -
+| style="background: #F5F5F5; padding: 5px;" |  -
 | style="background: #F5F5F5; padding: 5px;" |✔
-| style="background: #F5F5F5; padding: 5px;" | -
+| style="background: #F5F5F5; padding: 5px;" |  -
-| style="background: #F5F5F5; padding: 5px;" | -
+| style="background: #F5F5F5; padding: 5px;" |  -
-| style="background: #F5F5F5; padding: 5px;" | -
+| style="background: #F5F5F5; padding: 5px;" |  -
-| style="background: #F5F5F5; padding: 5px;" | -
+| style="background: #F5F5F5; padding: 5px;" |  -
 | style="background: #F5F5F5; padding: 5px;" |
 *Infections:
@@ Line 225: / Line 200: @@
 *Not indicated
 | style="background: #F5F5F5; padding: 5px;" |
 *Prolonged [[PR interval]]
 *Transient [[T wave]] inversions
 | style="background: #F5F5F5; padding: 5px;" |
@@ Line 235: / Line 210: @@
 | style="background: #F5F5F5; padding: 5px;" |✔
 | style="background: #F5F5F5; padding: 5px;" |✔
-| style="background: #F5F5F5; padding: 5px;" | -
+| style="background: #F5F5F5; padding: 5px;" |  -
 | style="background: #F5F5F5; padding: 5px;" |✔
 | style="background: #F5F5F5; padding: 5px;" |✔
-| style="background: #F5F5F5; padding: 5px;" | -
+| style="background: #F5F5F5; padding: 5px;" |  -
-| style="background: #F5F5F5; padding: 5px;" | -
+| style="background: #F5F5F5; padding: 5px;" |  -
-| style="background: #F5F5F5; padding: 5px;" | -
+| style="background: #F5F5F5; padding: 5px;" |  -
 | style="background: #F5F5F5; padding: 5px;" |
 *Ill-contact
@@ Line 259: / Line 234: @@
 **Masses or nodules ([[Anti-neutrophil cytoplasmic antibody|ANCA]]-associated granulomatous vasculitis)
 *On [[Magnetic resonance imaging|MRI]]:
-Homogeneous, circumferential [[Blood vessel|vessel]] wall [[swelling]]
+Homogeneous, circumferential [[Blood vessel|vessel]] wall [[swelling]]
 | style="background: #F5F5F5; padding: 5px;" |
 *[[Bundle branch block|Right or left bundle-branch block]] ([[Churg-Strauss syndrome]])
 *[[Atrial fibrillation]] ([[Churg-Strauss syndrome]])
 *Non-specific [[ST interval|ST segment]] and [[T wave]] changes
 | style="background: #F5F5F5; padding: 5px;" |
 *[[Nodule (medicine)|Nodules]]
@@ Line 273: / Line 249: @@
 | style="background: #F5F5F5; padding: 5px;" |✔
 | style="background: #F5F5F5; padding: 5px;" |✔
-| style="background: #F5F5F5; padding: 5px;" | -
+| style="background: #F5F5F5; padding: 5px;" |  -
 | style="background: #F5F5F5; padding: 5px;" |✔
 | style="background: #F5F5F5; padding: 5px;" |✔
@@ Line 302: / Line 278: @@
 | style="background: #F5F5F5; padding: 5px;" |✔
 | style="background: #F5F5F5; padding: 5px;" |✔
-| style="background: #F5F5F5; padding: 5px;" | -
+| style="background: #F5F5F5; padding: 5px;" |  -
-| style="background: #F5F5F5; padding: 5px;" | -
+| style="background: #F5F5F5; padding: 5px;" |  -
-| style="background: #F5F5F5; padding: 5px;" | -
+| style="background: #F5F5F5; padding: 5px;" |  -
 | style="background: #F5F5F5; padding: 5px;" |✔
 | style="background: #F5F5F5; padding: 5px;" |✔
-| style="background: #F5F5F5; padding: 5px;" | -
+| style="background: #F5F5F5; padding: 5px;" |  -
-| style="background: #F5F5F5; padding: 5px;" | -
+| style="background: #F5F5F5; padding: 5px;" |  -
-| style="background: #F5F5F5; padding: 5px;" | -
+| style="background: #F5F5F5; padding: 5px;" |  -
 | style="background: #F5F5F5; padding: 5px;" |
 *[[Smoking]]
@@ Line 324: / Line 300: @@
 {{WH}}
 {{WS}}
-[[Category:Medicine]]
+<br />[[Category:Medicine]]
 [[Category:Cardiology]]
 [[Category:Up-To-Date]]
 [[Category:Primary care]]
 [[Category:Emergency medicine]]
 [[Category:Intensive care medicine]]