Pericarditis physical examination: Difference between revisions
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Revision as of 17:50, 18 January 2013
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Pericarditis Microchapters |
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Pericarditis physical examination On the Web |
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American Roentgen Ray Society Images of Pericarditis physical examination |
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Risk calculators and risk factors for Pericarditis physical examination |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]
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.
Appearance of the Patient
- 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
- 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 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.
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
- ↑ Gwinnutt, C., Driscoll, P. (Eds) (2003) (2nd Ed.) Trauma Resuscitation: The Team Approach. Oxford: BIOS Scientific Publishers Ltd. ISBN 978-1859960097
- ↑ Dolan, B., Holt, L. (2000). Accident & Emergency: Theory into practice. London: Bailliere Tindall ISBN 978-0702022395
- ↑ Mattson Porth, C. (Ed.) (2005) (7th Ed.) Pathophysiology: Concepts of Altered Health States. Philadelphia : Lippincott Williams & Wilkins ISBN 978-0781749886