Pericarditis physical examination


 * Associate Editor-In-Chief:

'''Related chapters include complications of pericarditis such as cardiac tamponade, pericardial effusion and constrictive pericarditis '''

Overview
The classic sign of pericarditis is a 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&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, and rheumatic carditis)

Heart
A pericardial friction rub or pericardial rub is the classic physical examination finding in pericarditis. It is usually heard in the setting of 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 parts. 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.

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 that a Significant Pericardial Effusion and/or Cardiac Tamponade May be Present
Classical cardiac tamponade presents three signs, known as Beck's triad. Hypotension occurs because of decreased stroke volume, jugular venous distension due to impaired venous return to the heart, and muffled heart sounds due to fluid inside the pericardium Another sign of tamponade on physical examination includes pulsus paradoxus (a drop of at least 10 mmHg in arterial blood pressure on inspiration). There may also be general signs & 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 result in clicks.

Signs that Pericardial Constriction is Present

 * Elevation of the JVP (jugular venous pulse). The waveform of pericardial constriction is characteristic with a prominent x and y descent.
 * Kussmaul’s sign 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, can be seen in 20% of patients with pericardial constriction.
 * Widely split S2 can be heard and a pericardial knock can be heard in approximately 50% of patients.
 * Pulsatile liver, ascites, and scrotal edema.
 * Peripheral edema