Pericarditis physical examination: Difference between revisions

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{{Pericarditis}}


{{CMG}}  
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'''Associate Editor-In-Chief:''' {{CZ}}


{{Editor Join}}
==Overview==
The classic [[medical sign|sign]] of pericarditis is a [[pericardial rub|pericardial friction rub]]. A careful examination must be performed to exclude the presence of [[cardiac tamponade]], a dangerous complication of pericarditis. If [[cardiac tamponade]] is present, then [[pulsus paradoxus]], [[hypotension]], an elevated [[jugular venous pressure]], and [[peripheral edema]] may be present.


== Physical Examination ==
==Overview==
Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].


=== Appearance of the Patient with Pericarditis ===
OR
# [[Fever]] less than 39° C or 102.2° F
#* Patients who are elderly may not exhibit fever; however, they may be [[hypothermic]] especially those with [[renal failure]].
# [[Chills]] (suppurative pericarditis and idiopathic (viral) pericarditis)
# [[Weakness]]
# [[Depression]]
# [[Anxiety]]
# [[Pallor]] (may also indicate [[tuberculosis]], [[uremia]], [[neoplasia]], and rheumatic carditis)


=== Heart ===
Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].
'''Ausculatory Phenomena:'''
# Pericardial Rub(s): Usually heard with acute pericarditis, sometimes with subacute and chronic.  This is the major indicator of pericarditis.
#* endopericardial rub: inflamed, scarred or tumor-invaded serosal surfaces
#* exopericardial rub: after sclerotherapy of effusions, between parietal pericardium and pleura or chest wall (occasionally)
#* endo-exopericardial rub: both of the above
#* pleuropericardial rub: [[pleuritis]] as a result of pleural or both pleural and pericardial both
# Abnormal Heart Sounds:
#* Sounds are dampened as a result of fluid insullation
#* Hemodynamic changes diminish S<sub>1</sub> and S<sub>2</sub>
# Clicks: Ventricular volume shrinks disproportionately and psuedoprolapse/true prolapse of mitral and/or tricuspid valvular structures result in clicks.
# Murmurs: are epiphenomena and may be present if there is coinciding heart disease, narrowing of a valve, aorta, pulmonary artery or another area of the heart.
=== Lungs ===


[[Rales]] are frequent examination findings, occasionally [[pleural fluid]] may present.
OR


=== Extremities ===
The presence of [finding(s)] on physical examination is diagnostic of [disease name].
#May be poorly perfused in the setting of tamponade
#Edema may be present in the setting of pericardial constriction


==See Also==
OR
 
The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
 
==Physical Examination==
Physical examination of patients with [disease name] is usually normal.
 
OR
 
Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
 
OR
 
The presence of [finding(s)] on physical examination is diagnostic of [disease name].
 
OR
 
The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
 
===Appearance of the Patient===
*Patients with pericarditis usually appear [general appearance].
 
===Vital Signs===
 
*High-grade / low-grade fever
*[[Hypothermia]] / hyperthermia may be present
*[[Tachycardia]] with regular pulse or (ir)regularly irregular pulse
*[[Bradycardia]] with regular pulse or (ir)regularly irregular pulse
*Tachypnea / bradypnea
*Kussmal respirations may be present in _____ (advanced disease state)
*Weak/bounding pulse / pulsus alternans / paradoxical pulse / asymmetric pulse
*High/low blood pressure with normal pulse pressure / [[wide pulse pressure]] / [[narrow pulse pressure]]
 
===Skin===
* Skin examination of patients with pericarditis is usually normal.
 
* [[Pallor]] may be seen in the patients that pericarditis is secondary to [[tuberculosis]], [[uremia]], [[neoplasia]], or rheumatic carditis
 
===HEENT===
* HEENT examination of patients with pericarditis is usually normal.
 
===Neck===
* Neck examination of patients with [disease name] is usually normal.
OR
*[[Jugular venous distension]]
*[[Carotid bruits]] may be auscultated unilaterally/bilaterally using the bell/diaphragm of the otoscope
*[[Lymphadenopathy]] (describe location, size, tenderness, mobility, and symmetry)
*[[Thyromegaly]] / thyroid nodules
*[[Hepatojugular reflux]]
 
===Lungs===
* Pulmonary examination of patients with [disease name] is usually normal.
OR
* Asymmetric chest expansion OR decreased chest expansion
*Lungs are hyporesonant OR hyperresonant
*Fine/coarse [[crackles]] upon auscultation of the lung bases/apices unilaterally/bilaterally
*Rhonchi
*Vesicular breath sounds OR distant breath sounds
*Expiratory wheezing OR inspiratory wheezing with normal OR delayed expiratory phase
*[[Wheezing]] may be present
*[[Egophony]] present/absent
*[[Bronchophony]] present/absent
*Normal/reduced [[tactile fremitus]]
 
===Heart===
* Cardiovascular examination of patients with [disease name] is usually normal.
OR
*Chest tenderness upon palpation
*PMI within 2 cm of the sternum  (PMI) / Displaced point of maximal impulse (PMI) suggestive of ____
*[[Heave]] / [[thrill]]
*[[Friction rub]]
*[[Heart sounds#First heart tone S1, the "lub"(components M1 and T1)|S1]]
*[[Heart sounds#Second heart tone S2 the "dub"(components A2 and P2)|S2]]
*[[Heart sounds#Third heart sound S3|S3]]
*[[Heart sounds#Fourth heart sound S4|S4]]
*[[Heart sounds#Summation Gallop|Gallops]]
*A high/low grade early/late [[systolic murmur]] / [[diastolic murmur]] best heard at the base/apex/(specific valve region) may be heard using the bell/diaphgram of the stethoscope
 
===Abdomen===
* Abdominal examination of patients with [disease name] is usually normal.
OR
*[[Abdominal distension]]
*[[Abdominal tenderness]] in the right/left upper/lower abdominal quadrant
*[[Rebound tenderness]] (positive Blumberg sign)
*A palpable abdominal mass in the right/left upper/lower abdominal quadrant
*Guarding may be present
*[[Hepatomegaly]] / [[splenomegaly]] / [[hepatosplenomegaly]]
*Additional findings, such as obturator test, psoas test, McBurney point test, Murphy test
 
===Back===
* Back examination of patients with [disease name] is usually normal.
OR
*Point tenderness over __ vertebrae (e.g. L3-L4)
*Sacral edema
*Costovertebral angle tenderness bilaterally/unilaterally
*Buffalo hump
 
===Genitourinary===
* Genitourinary examination of patients with [disease name] is usually normal.
OR
*A pelvic/adnexal mass may be palpated
*Inflamed mucosa
*Clear/(color), foul-smelling/odorless penile/vaginal discharge
 
===Neuromuscular===
* Neuromuscular examination of patients with pericarditis is usually normal.
OR
*Patient is usually oriented to persons, place, and time
* Altered mental status
* Glasgow coma scale is ___ / 15
* Clonus may be present
* Hyperreflexia / hyporeflexia / areflexia
* Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
* Muscle rigidity
* Proximal/distal muscle weakness unilaterally/bilaterally
* ____ (finding) suggestive of cranial nerve ___ (roman numerical) deficit (e.g. Dilated pupils suggestive of CN III deficit)
*Unilateral/bilateral upper/lower extremity weakness
*Unilateral/bilateral sensory loss in the upper/lower extremity
*Positive straight leg raise test
*Abnormal gait (describe gait: e.g. ataxic (cerebellar) gait / steppage gait / waddling gait / choeiform gait / Parkinsonian gait / sensory gait)
*Positive/negative Trendelenburg sign
*Unilateral/bilateral tremor (describe tremor, e.g. at rest, pill-rolling)
*Normal finger-to-nose test / Dysmetria
*Absent/present dysdiadochokinesia (palm tapping test)
 
===Extremities===
* Extremities examination of patients with pericarditis is usually normal.
 
==Appearance of the Patient==
*[[Fever]] less than 39&deg;C or 102.2&deg;F
** Patients who are elderly may not exhibit [[fever]]; however, they may be [[hypothermic]], especially those with [[renal failure]].
*[[Chills]] (suppurative pericarditis and idiopathic viral pericarditis)
*[[Weakness]]
*[[Anxiety]]
*[[Pallor]] (may also indicate [[tuberculosis]], [[uremia]], [[neoplasia]], or rheumatic carditis)
 
==Heart==
A [[pericardial rub]] or [[pericardial friction rub]] is the classic physical examination finding in pericarditis. It is usually heard in the setting of an acute pericarditis, and occasionally with either subacute or chronic pericarditis. It is best heard with the diaphragm of the stethoscope. [[Inflammation]] of the pericardial sac causes the parietal and visceral surfaces of the roughened [[pericardium]] to rub against each other. This produces an [[extra cardiac sound]] of to-and-fro character with both systolic and diastolic components. One, two, or three components of a [[pericardial friction rub]] may be audible. A three-component rub indicates the presence of [[pericarditis]] and serves to distinguish a pericardial rub from a [[pleural friction rub]], which ordinarily has two components. It resembles the sound of squeaky leather and is often described as grating, scratching, or rasping. The sound may seem louder than or may even mask the other [[heart sound]]s. Friction rubs are usually best heard between the apex and [[sternum]] but may be widespread. The sound has three components, two diastolic and one systolic.<br>
There are several different [[pericardial rub]]s that can be auscultated:
===Endopericardial Rub===
This rub occurs as the result of inflamed, scarred or tumor-invaded serosal surfaces of [[pericardium]].
===Exopericardial Rub===
This rub occurs after [[sclerotherapy]] of effusions, and is due to friction between the parietal [[pericardium]] and the [[pleura]] (or occasionally the chest wall).
===Endo-exopericardial Rub===
This rub occurs with both of the above.
===Pleuropericardial Rub===
This rub occurs as a result of both pleural and pericardial [[inflammation]].
 
==Signs of Significant Pericardial Effusion or Cardiac Tamponade==
Classical [[cardiac tamponade]] presents three signs, known as [[Beck's triad]].<ref>Gwinnutt, C., Driscoll, P. (Eds) (2003) (2nd Ed.) Trauma Resuscitation: The Team Approach. Oxford: BIOS Scientific Publishers Ltd. ISBN 978-1859960097 </ref> Beck's triad consists of [[hypotension]] due to a decreased [[stroke volume]], [[jugular venous distension]] due to impaired venous return to the heart, and muffled [[heart sounds]] due to fluid inside the pericardium.<ref>Dolan, B., Holt, L. (2000). Accident & Emergency: Theory into practice. London: Bailliere Tindall ISBN 978-0702022395</ref> Another sign of tamponade on physical examination includes [[pulsus paradoxus]] (a drop of at least 10 mmHg in arterial [[blood pressure]] on [[inspiration]]).<ref>Mattson Porth, C. (Ed.) (2005) (7th Ed.) Pathophysiology: Concepts of Altered Health States. Philadelphia : Lippincott Williams & Wilkins ISBN 978-0781749886 </ref> There may also be general signs and symptoms of cardiogenic [[shock]] (such as [[tachycardia]], [[breathlessness]], poor perfusion of the extremities, and decreasing [[Glasgow coma scale|level of consciousness]]). [[Peripheral edema]] may be present. Hemodynamic changes diminish S<sub>1</sub> and S<sub>2</sub>. As ventricular volume shrinks disproportionately, there may be psuedoprolapse/true prolapse of mitral and/or tricuspid valvular structures that results in clicking sounds.
[[Image:150072-1332319-156951-1951463.jpg|thumb|left|Recording of aortic pressure showing [[pulsus paradoxus]]. Systolic pressure declines 20 mmHg on [[inspiration]].]]


* [[Hemopericardium]]
* [[Pneumopericardium]]
* [[Chylopericardium]]
* [[Pericardial effusion]]
* [[Congenital absence of the pericardium]]
* [[Pericardial window]]
* [[Pericardial sac]]
* [[Pericardial friction rub]]
* [[Pericardiectomy]]
* [[Pericardiocentesis]]
* [[Pericardium]]


==References==
{{Reflist|2}}


== Acknowledgements ==
The content on this page was first contributed by [[C. Michael Gibson, M.S., M.D.]]


==Additional Resources==
{{refbegin|2}}
* Adler Y, Finkelstein Y, Guindo J, de la Serna R, Shoenfeld Y, Bayes-Genis A, Sagie A, Bayes de Luna A, Spodick DH. Colchicine treatment for recurrent pericarditis: a decade of experience. Circulation. 1998;97:2183–2185.
* Applegate RJ, Johnston WE, Vinten-Johansen J, Klopfenstein HS, Little WC. Restraining effect of intact pericardium during acute volume leading. Am J Physiol. 1992;262:H1725–H1733.
* Artom G, Koren-Morag N, Spodick DH, Brucato A, Guindo J, Bayesde-Luna A, Brambilla G, Finkelstein Y, Granel B, Bayes-Genis A, Schwammenthal E, Adler Y. Pretreatment with corticosteroids attenuates the efficacy of colchicine in preventing recurrent pericarditis: a multicentre all-case analysis. Eur Heart J. 2005;26:723–727.
* Arunasalam S, Siegel RJ. Rapid resolution of symptomatic acute pericarditis with ketorolac tromethamine: a parenteral nonsteroidal antiinflammatory agent. Am Heart J. 1993;125(pt 1):1455–1458.
* Bonnefoy E, Gordon P, Kirkorian G, Fatemi M, Chevalier P, Touboul P. Serum cardiac troponin I and ST-segment elevation in patients with acute pericarditis. Eur Heart J. 2000;21:832–836.
* Correale E, Maggioni AP, Romano S, Ricciardiello V, Battista R, Salvarola G, Santoro E, Tognoni G, on behalf of the Gruppo Italiano perlo Studio della Sopravvivenza nell’Infarto Miocardico (GISSI). Comparison of frequency, diagnostic and prognostic significance of pericardial involvement in acute myocardial infarction treated with and without thrombolytics. Am J Cardiol. 1993;71:1377–1381.
* Fowler NO. Tuberculous pericarditis. JAMA. 1991;266:99 –103.
* Freeman GL, LeWinter MM. Determinants of the intrapericardial pressure in dogs. J Appl Physiol. 1986;60:758 –764.
* Freeman GL, LeWinter MM. Pericardial adaptations during chronic cardiac dilation in dogs. Circ Res. 1984;54:294 –300.
* Freeman GL, Little WC. Comparison of in situ and in vitro studies of pericardial pressure-volume relation in the dog. Am J Physiol. 1986;251: H421–H427.
* Gunukula SR, Spodick DH. Pericardial disease in renal patients. Semin Nephrol. 2001;21:52–56.
* Hoit BD, Gabel M, Fowler NO. Cardiac tamponade in left ventricular dysfunction. Circulation. 1990;82:1370–1376.
* Imazio M, Bobbio M, Cecchi E, Demarie D, Demichellis B, Pomari F, Moratti M, Gaschino G, Giammaria M, Ghiso A, Belli R, Trinchero R. Colchicine in addition to conventional therapy for acute pericarditis: results of the COlchicine for acute PEricarditis (COPE) Trial. Circulation. 2005;112:2012–2016.
* Imazio M, Demichellis B, Cecchi E, Belli R, Ghisio A, Bobbio M, Trinchero R. Cardiac troponin I in acute pericarditis. J Am Coll Cardiol. 2003;42:2144–2148.
* Imazio M, Demichellis B, Parrini I, Gluggia M, Cecchi E, Gaschino G, Demarie D, Ghislo A, Trinchero R. Day-hospital treatment of acute pericarditis: a management program for outpatient therapy. J Am Coll Cardiol. 2004;43:1042–1046.
* Jerjes-Sanchez C, Ramirez-Rivera A, Ibarra-Perez C. The Dressler syndrome after pulmonary embolism. Am J Cardiol. 1996;78:343–345.
* Kansal S, Roitman D, Sheffield LT. Two-dimensional echocardiography of congenital absence of pericardium. Am Heart J. 1985;109:912–915.
* Klopfenstein HS, Schuchard GH, Wann LS, Palmer TE, Hartz AJ, Gross CM, Singh S, Brooks HL. The relative merits of pulsus paradoxus and right ventricular diastolic collapse in the early detection of cardiac tamponade: an experimental echocardiographic study. Circulation. 1985;71: 829–833.
* Knopf WD, Talley JD, Murphy DA. An echo-dense mass in the pericardial space as a sign of left ventricular free wall rupture during acute myocardial infarction. Am J Cardiol. 1987;59:1202.
* Lange RA, Hillis D. Acute pericarditis. N Engl J Med. 2004;351: 2195–2202.
* LeWinter MM, Kabbani S. Pericardial diseases. In: Zipes DP, Libby P, Bonow RO, Braunwald E, eds. Braunwald’s Heart Disease. 7th ed. Philadelphia, Pa: Elsevier Saunders; 2005:1757–1780.
* Maisch B, Ristic D, Pankuweit S. Intrapericardial treatment of autoreactive pericardial effusion with triamcinolone. Eur Heart J. 2002;23: 1503–1508.
* Maisch B, Seferovic PM, Ristic AD, Erbel R, Rienmuller R, Adler Y, Tomkowski WZ, Thiene G, Yacoub MH, for the Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. Guidelines on the diagnosis and management of pericardial diseases: executive summary. Eur Heart J. 2004;25:587– 610.
* Maisch B. Recurrent pericarditis: mysterious or not so mysterious? Eur Heart J. 2005;26:631– 633.
* Mandell BF. Cardiovascular involvement in systemic lupus erythematosus. Semin Arthritis Rheum. 1987;17:126 –141.
* Miyazaki T, Pride HP, Zipes DP. Prostaglandins in the pericardial fluid modulate neural regulation of cardiac electrophysiological properties. Circ Res. 1990;66:163–175.
* Park JH, Choo SJ, Park SW. Acute pericarditis caused by acrylic bone cement after percutaneous vertebroplasty. Circulation. 2005; 111:e98.
* Permanyer-Miralda G, Sagrista-Sauleda J, Soler-Soler J. Primary acute pericardial disease: a prospective series of 231 consecutive patients. Am J Cardiol. 1985;56:623– 630.
* Permanyer-Miralda G. Acute pericardial disease: approach to the aetiologic diagnosis. Heart. 2004;90:252–254.
* Reddy PS, Curtiss EI, O’Toole JD, Shaver JA. Cardiac tamponade: hemodynamic observations in man. Circulation. 1978;58:265–272.
* Reddy PS, Curtiss EI, Uretsky BF. Spectrum of hemodynamic changes in cardiac tamponade. Am J Cardiol. 1990;66:1487–1491.
* Shabetai R, Fowler NO, Guntheroth WG. The hemodynamics of cardiac tamponade and constrictive pericarditis. Am J Cardiol. 1970;26: 480–489.
* Shabetai R. Pericardial effusion: haemodynamic spectrum. Heart. 2004; 90:255–256.
* Shabetai R. Recurrent pericarditis: recent advances and remaining questions. Circulation. 2005;112:1921–1923.
* Singh S, Wann S, Schuchard GH, Klopfenstein HS, Leimgruber PP, Keelan MH, Brooks HL. Right ventricular and right atrial collapse in patients with cardiac tamponade: a combined echocardiographic and hemodynamic study. Circulation. 1984;70:966–971.
* Spodick DH. Acute cardiac tamponade. N Engl J Med. 2003;349: 684–690.
* Spodick DH. Acute pericarditis: current concepts and practice. JAMA. 2003;289:1150 –1153.
* Spodick DH. Intrapericardial treatment of persistent autoreactive pericarditis / myopericarditis and pericardial effusion. Eur Heart J. 2002;23: 1481–1482.
* Spodick DH. Macrophysiology, microphysiology, and anatomy of the pericardium: a synopsis. Am Heart J. 1992;124:1046 –1051.
* Troughton RW, Asher CR, Klein AL. Pericarditis. Lancet. 2004;363: 717–727.
* Tsang TS, Barnes ME, Hayes SN, Freeman WK, Dearani JA, Butler SL, Seward JB. Clinical and echocardiographic characteristics of significant pericardial effusions following cardiothoracic surgery and outcomes of echo-guided pericardiocentesis for management: Mayo Clinic experience, 1979–1998. Chest. 1999;116:322–331.
* Tsang TS, Oh JK, Seward JB, Tajik AJ. Diagnostic value of echocardiography in cardiac tamponade. Herz. 2000;25:734–740.
* Zayas R, Anguita M, Torres F, Gimenez D, Bergillos F, Ruiz M, Ciudad M, Gallardo A, Valles F. Incidence of specific etiology and role of methods for specific etiologic diagnosis of primary acute pericarditis. Am J Cardiol. 1995;75:378 –382.
{{refend}}


== Suggested Links and Web Resources ==
* [http://www.mayoclinic.com/invoke.cfm?objectid=CE3BC2CF-B4C1-4401-8F0F9E0B7C284538&dsection=1 Pericarditis] - Mayo Clinic series
* [http://cardiologychannel.com/pericarditis/diagnosis.shtml Pericarditis] - cardiologychannel.com
* [http://heartcenter.seattlechildrens.org/conditions_treated/pericarditis.asp Pericarditis information] from Seattle Children's Hospital Heart Center
* [http://www.jpgmonline.com/article.asp?issn=0022-3859;year=2002;volume=48;issue=1;spage=46;epage=9;aulast=Khasnis Pulsus paradoxus] - Journal of Postgraduate Medicine
* http://en.wikipedia.org/wiki/Pericarditis
* [http://www.SeeMyHeart.org SeeMyHeart] - Patient Information on Echocardiograms (Heart Ultrasounds)
* [http://www.asecho.org American Society] of Echocardiography
* [http://www.ptca.org/imaging/stress_test.html Stress Test with Echocardiography] from Angioplasty.Org
* [http://heartcenter.seattlechildrens.org/what_to_expect/echocardiogram.asp Echocardiography information] from Children's Hospital Heart Center, Seattle.
* [http://know-heart-diseases.com Coronary heart disease] And echocardiography
* [http://www.echocardiology.org Echocardiography Resources] Simple echocardiography tutorials
* [http://www.manbit.com/ERS/ERSindex.asp Atlas of Echocardiography] Echocardiography Database
* [http://www2.umdnj.edu/~shindler/index.html E-chocardiography] Internet Journal of Cardiac Ultrasound
* [http://www.echobasics.de Echobasics] Basic introduction to echocardiography - German/Spanish English planned for 2007
* [http://www.mitral.com/echocardiography.shtml Echocardiography] Basic information about echocardiography - HealthwoRx


== For Patients ==


* [http://www.mssm.edu/cvi/pericarditis.shtml#q1 Pericarditis]


{{Electrocardiography}}
{{Circulatory system pathology}}
{{SIB}}
[[Category:Cardiology]]
[[Category:Diseases involving the fasciae]]
[[Category:Inflammations]]
[[Category:Emergency medicine]]


Copyleft image obtained courtesy of Zhi Zhou, MD.
==Signs of Pericardial Constriction==
*Elevation of the [[JVP]] ([[jugular venous pulse]]): The waveform of [[pericardial constriction]] is characteristic with a prominent 'x' and 'y' descent.
*[[Kussmaul’s sign]]: It may be found in about 10% of patients. It occurs because the fall in intrathoracic pressure during [[inspiration]] is not transmitted to the cardiac chambers and pericardial space.
*[[Pulsus paradoxus]]: Though more typical in [[cardiac tamponade]], it can be seen in 20% of patients with [[pericardial constriction]].
*Widely split [[S2]] and a pericardial knock: They can be present in approximately 50% of patients.
*Pulsatile liver, [[ascites]], and scrotal [[edema]]
*[[Peripheral edema]]


==References==
{{Reflist|2}}
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Latest revision as of 23:39, 29 July 2020

Pericarditis Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2] Homa Najafi, M.D.[3]

Overview

The classic sign of pericarditis is a pericardial friction rub. A careful examination must be performed to exclude the presence of cardiac tamponade, a dangerous complication of pericarditis. If cardiac tamponade is present, then pulsus paradoxus, hypotension, an elevated jugular venous pressure, and peripheral edema may be present.

Overview

Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].

OR

Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

The presence of [finding(s)] on physical examination is diagnostic of [disease name].

OR

The presence of [finding(s)] on physical examination is highly suggestive of [disease name].

Physical Examination

Physical examination of patients with [disease name] is usually normal.

OR

Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].

OR

The presence of [finding(s)] on physical examination is diagnostic of [disease name].

OR

The presence of [finding(s)] on physical examination is highly suggestive of [disease name].

Appearance of the Patient

  • Patients with pericarditis usually appear [general appearance].

Vital Signs

  • High-grade / low-grade fever
  • Hypothermia / hyperthermia may be present
  • Tachycardia with regular pulse or (ir)regularly irregular pulse
  • Bradycardia with regular pulse or (ir)regularly irregular pulse
  • Tachypnea / bradypnea
  • Kussmal respirations may be present in _____ (advanced disease state)
  • Weak/bounding pulse / pulsus alternans / paradoxical pulse / asymmetric pulse
  • High/low blood pressure with normal pulse pressure / wide pulse pressure / narrow pulse pressure

Skin

  • Skin examination of patients with pericarditis is usually normal.

HEENT

  • HEENT examination of patients with pericarditis is usually normal.

Neck

  • Neck examination of patients with [disease name] is usually normal.

OR

Lungs

  • Pulmonary examination of patients with [disease name] is usually normal.

OR

  • Asymmetric chest expansion OR decreased chest expansion
  • Lungs are hyporesonant OR hyperresonant
  • Fine/coarse crackles upon auscultation of the lung bases/apices unilaterally/bilaterally
  • Rhonchi
  • Vesicular breath sounds OR distant breath sounds
  • Expiratory wheezing OR inspiratory wheezing with normal OR delayed expiratory phase
  • Wheezing may be present
  • Egophony present/absent
  • Bronchophony present/absent
  • Normal/reduced tactile fremitus

Heart

  • Cardiovascular examination of patients with [disease name] is usually normal.

OR

  • Chest tenderness upon palpation
  • PMI within 2 cm of the sternum (PMI) / Displaced point of maximal impulse (PMI) suggestive of ____
  • Heave / thrill
  • Friction rub
  • S1
  • S2
  • S3
  • S4
  • Gallops
  • A high/low grade early/late systolic murmur / diastolic murmur best heard at the base/apex/(specific valve region) may be heard using the bell/diaphgram of the stethoscope

Abdomen

  • Abdominal examination of patients with [disease name] is usually normal.

OR

Back

  • Back examination of patients with [disease name] is usually normal.

OR

  • Point tenderness over __ vertebrae (e.g. L3-L4)
  • Sacral edema
  • Costovertebral angle tenderness bilaterally/unilaterally
  • Buffalo hump

Genitourinary

  • Genitourinary examination of patients with [disease name] is usually normal.

OR

  • A pelvic/adnexal mass may be palpated
  • Inflamed mucosa
  • Clear/(color), foul-smelling/odorless penile/vaginal discharge

Neuromuscular

  • Neuromuscular examination of patients with pericarditis is usually normal.

OR

  • Patient is usually oriented to persons, place, and time
  • Altered mental status
  • Glasgow coma scale is ___ / 15
  • Clonus may be present
  • Hyperreflexia / hyporeflexia / areflexia
  • Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
  • Muscle rigidity
  • Proximal/distal muscle weakness unilaterally/bilaterally
  • ____ (finding) suggestive of cranial nerve ___ (roman numerical) deficit (e.g. Dilated pupils suggestive of CN III deficit)
  • Unilateral/bilateral upper/lower extremity weakness
  • Unilateral/bilateral sensory loss in the upper/lower extremity
  • Positive straight leg raise test
  • Abnormal gait (describe gait: e.g. ataxic (cerebellar) gait / steppage gait / waddling gait / choeiform gait / Parkinsonian gait / sensory gait)
  • Positive/negative Trendelenburg sign
  • Unilateral/bilateral tremor (describe tremor, e.g. at rest, pill-rolling)
  • Normal finger-to-nose test / Dysmetria
  • Absent/present dysdiadochokinesia (palm tapping test)

Extremities

  • Extremities examination of patients with pericarditis is usually normal.

Appearance of the Patient

Heart

A pericardial rub or pericardial friction rub is the classic physical examination finding in pericarditis. It is usually heard in the setting of an acute pericarditis, and occasionally with either subacute or chronic pericarditis. It is best heard with the diaphragm of the stethoscope. Inflammation of the pericardial sac causes the parietal and visceral surfaces of the roughened pericardium to rub against each other. This produces an extra cardiac sound of to-and-fro character with both systolic and diastolic components. One, two, or three components of a pericardial friction rub may be audible. A three-component rub indicates the presence of pericarditis and serves to distinguish a pericardial rub from a pleural friction rub, which ordinarily has two components. It resembles the sound of squeaky leather and is often described as grating, scratching, or rasping. The sound may seem louder than or may even mask the other heart sounds. Friction rubs are usually best heard between the apex and sternum but may be widespread. The sound has three components, two diastolic and one systolic.
There are several different pericardial rubs that can be auscultated:

Endopericardial Rub

This rub occurs as the result of inflamed, scarred or tumor-invaded serosal surfaces of pericardium.

Exopericardial Rub

This rub occurs after sclerotherapy of effusions, and is due to friction between the parietal pericardium and the pleura (or occasionally the chest wall).

Endo-exopericardial Rub

This rub occurs with both of the above.

Pleuropericardial Rub

This rub occurs as a result of both pleural and pericardial inflammation.

Signs of Significant Pericardial Effusion or Cardiac Tamponade

Classical cardiac tamponade presents three signs, known as Beck's triad.[1] Beck's triad consists of hypotension due to a decreased stroke volume, jugular venous distension due to impaired venous return to the heart, and muffled heart sounds due to fluid inside the pericardium.[2] Another sign of tamponade on physical examination includes pulsus paradoxus (a drop of at least 10 mmHg in arterial blood pressure on inspiration).[3] There may also be general signs and symptoms of cardiogenic shock (such as tachycardia, breathlessness, poor perfusion of the extremities, and decreasing level of consciousness). Peripheral edema may be present. Hemodynamic changes diminish S1 and S2. As ventricular volume shrinks disproportionately, there may be psuedoprolapse/true prolapse of mitral and/or tricuspid valvular structures that results in clicking sounds.

Recording of aortic pressure showing pulsus paradoxus. Systolic pressure declines 20 mmHg on inspiration.





Copyleft image obtained courtesy of Zhi Zhou, MD.

Signs of Pericardial Constriction

References

  1. ↑ Gwinnutt, C., Driscoll, P. (Eds) (2003) (2nd Ed.) Trauma Resuscitation: The Team Approach. Oxford: BIOS Scientific Publishers Ltd. ISBN 978-1859960097
  2. ↑ Dolan, B., Holt, L. (2000). Accident & Emergency: Theory into practice. London: Bailliere Tindall ISBN 978-0702022395
  3. ↑ Mattson Porth, C. (Ed.) (2005) (7th Ed.) Pathophysiology: Concepts of Altered Health States. Philadelphia : Lippincott Williams & Wilkins ISBN 978-0781749886

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