Patients with pericardial effusion may have unremarkable physical exams but often present with tachycardia, distant heart sounds and tachypnea. A physical finding specific to pericardial effusion is dullness to percussion, bronchial breath sounds and egophony over the inferior angle of the left scapula. This phenomenon is known as Ewart's sign and is due to compression of the left lung base. Patients with concern for cardiac tamponade may present with abnormal vitals and what's classically known as the Beck's triad, which consists of hypotension (low blood pressure), jugular venous distension and distant heart sounds. Though these are the classical findings; all three occur simultaneously in only a minority of patients. Patients presenting with cardiac tamponade may also be evaluated for pulsus paradoxus. Pulsus paradoxus is a phenomenon in which systolic blood pressure drops by 10 mmHg or more during inspiration. In cardiac tamponade, the pressure within the pericardium is significantly higher, hence decreasing the compliance of the chambers (the capacity to expand/ conform to volume changes). During inspiration, right ventricle filling in increased, which causes the Interventricular septum to bulge into the left ventricle, hence leading to reduced left ventricular filling and consequently reduced stroke volume and low systolic blood pressure. Exams Chest X-ray showing a massive pericardial effusion: Water bottle sign EKG: sinus tachycardia with low QRS voltage and electrical alternans Some patients with pericardial effusions may present with no symptoms and the<unk>  can be an incidental finding due to imaging of other illnesses. Patients who present with dyspnea or chest pain have a broad differential<unk>  and it may be necessary to rule out other causes like myocardial infarction, pulmonary embolism, pneumothorax, acute pericarditis, pneumonia, and esophageal rupture. Initial tests include electrocardiography (ECG) and chest x-ray. Chest x-ray: is non-specific and may not help identify a pericardial effusion but a very large, chronic effusion can present as "water-bottle sign" on an x-ray, which occurs when the cardiopericardial silhouette is enlarged and assumes the shape of a flask or water bottle. Chest radiograph is also helpful in ruling out pneumothorax, pneumonia, and esophageal rupture. ECG: may present with sinus tachycardia, low voltage QRS as well as electrical alternans. Due to the fluid accumulation around the heart, the heart is further away from the chest leads, which leads to the low voltage QRS. Electrical alternans signifies the up-and-down change of the QRS amplitude with every beat due to the heart swinging in the fluid (as displayed in the ultrasound image in the introduction) . These three findings together should raise suspicion for impending hemodynamic instability associated with cardiac tamponade. Echocardiogram (ultrasound): when pericardial effusion is suspected, echocardiography usually confirms the<unk>  and allows assessment of the size, location and signs of hemodynamic instability. A transthoracic echocardiogram (TTE) is usually sufficient to evaluate pericardial effusion and it may also help distinguish pericardial effusion from pleural effusion and MI. Most pericardial effusions appear as an anechoic area (black or without an echo) between the visceral and the parietal membrane. Complex or malignant effusions are more heterogeneous in appearance, meaning they may have variations in echo on ultrasound. TTE can also differentiate pericardial effusion based on the size. Although it's difficult to define size classifications because they vary with institutions, most commonly they are as follows: small 20. An echocardiogram is urgently needed for evaluation when there is concern for hemodynamic compromise, a rapidly developing effusion or history of recent cardiac surgery/procedures. Cardiac CT and MRI scans: cross-sectional imaging with computed tomography (CT) can help localize and quantify the effusion, especially in a loculated effusion (a effusion contained to one area). CT imaging also helps assess for pericardial pathology (pericardial thickening, constrictive pericarditis, malignancy-associated pericarditis). Whereas cardiac MRI is reserved for patients with poor echocardiogram findings and for assessing pericardial inflammation, especially for patients with continued inflammation despite treatment. CT and MRI imaging can also be used for continued follow up on patients. Pericardiocentesis: is a procedure in which fluid is aspirated from the pericardial cavity with a needle and catheter. This procedure can be used to analyze the fluid but more importantly can also provide symptomatic relief, especially in patients with hemodynamic compromise. Pericardiocentesis is usually guided by an echocardiogram to determine the exact location of the effusion and the optimal location of puncture site to minimize risk of complications. After the procedure, the aspirated fluid is analyzed for gross appearance (color, consistency, bloody), cell count, and concentration of glucose, protein, and other cellular components (for example lactate dehydrogenase). Fluid may be also sent for gram stain, acid fast stain, or culture if high suspicion of infectious cause. Bloody fluids may also be evaluated for malignant cells. Fluid analysis may result in: * transudative effusion: due to non-inflammatory causes (congestive heart failure , myxoedema , nephrotic syndrome ) * exudative effusion: inflammatory or malignant causes (tuberculosis , spread from empyema , metastasis) * hemorrhagic effusion: high blood concentration (trauma, rupture of aneurysms, malignant effusion) File:PericaridaleffusionCT.A CT scan showing a pericardial effusion File:Hemorragic effusion.A large anechoic (black) pericardial effusion as seen on ultrasound. Closed arrow: the heart, open arrow: the effusion File:Tamponade.Pericardial effusion due to malignancy. Note bulbous heart and primary lung cancer in right upper lobe. File:Pericardiocentesis.Pericardiocentesis: fluid aspiration of hemorrhagic effusion
medical diagnosis of Pericarditis
medical cause of Constrictive pericarditis
medical cause of Pericarditis
medical cause of Myocardial infarction
medical cause of Myocarditis
medical cause of Chest pain
complications of Pericarditis
medical cause of Ventricular fibrillation