What are the key components of a physical examination for a patient suspected of having pericardial effusion, particularly with a history of cardiovascular conditions, cancer, or recent cardiac surgery?

Physical Examination for Pericardial Effusion

The physical examination may be completely normal in patients without hemodynamic compromise, but when cardiac tamponade develops, the classic triad includes neck vein distension with elevated jugular venous pressure, pulsus paradoxus, and diminished heart sounds on cardiac auscultation. 1

Vital Signs Assessment

• Measure blood pressure in both arms if aortic dissection is in the differential diagnosis 1
• Document heart rate, as sinus tachycardia commonly reflects compensatory response to reduced blood pressure from pericardial fluid compression 1
• Check temperature, as fever may indicate infectious or immune-mediated pericarditis rather than isolated effusion 1

Cardiovascular Examination

Jugular Venous Pressure

• Assess for neck vein distension with elevated jugular venous pressure at bedside examination, which is a classic sign of tamponade physiology 1

Pulsus Paradoxus

• Measure pulsus paradoxus (>10 mmHg drop in systolic blood pressure during inspiration), which indicates hemodynamic compromise from cardiac tamponade 1

Cardiac Auscultation

• Listen for diminished or muffled heart sounds, which occur with moderate to large effusions due to fluid insulation between the stethoscope and heart 1, 2
• Auscultate for pericardial friction rubs, though these are rarely heard in isolated effusion and typically indicate concomitant pericarditis 1

Signs of Left Ventricular Dysfunction

• Examine for rales and S3 gallop, as these findings suggest underlying severe coronary artery disease or myocardial involvement and portend higher risk 1
• Assess for acute mitral regurgitation murmur, which identifies patients at high risk of poor outcomes 1

Assessment for Precipitating Causes

Hypertension

• Identify uncontrolled hypertension as a potential precipitating cause of myocardial ischemia that may have led to pericardial involvement 1

Thyroid Disease

• Look for signs of thyrotoxicosis or hypothyroidism, as both can cause pericardial effusion 1, 3

Vascular Disease

• Examine peripheral pulses and auscultate for bruits, as extracardiac vascular disease suggests higher likelihood of significant coronary artery disease 1
• Check for unequal pulses and aortic regurgitation murmur if aortic dissection is suspected 1

Signs of Hemodynamic Compromise

• Assess for hypotension and evidence of organ hypoperfusion, which constitute a medical emergency requiring immediate pericardiocentesis 1
• Evaluate for signs of cardiogenic shock (hypotension, altered mental status, cool extremities, oliguria), which occurs in up to 5% of patients with cardiac complications and carries >60% mortality 1

Respiratory Examination

• Assess for differential breath sounds and pleuritic chest pain to exclude pneumothorax as an alternative diagnosis 1
• Document dyspnea and orthopnea, which are classic symptoms reflecting pericardial fluid compression on cardiac chambers 1

Key Clinical Pitfalls

The physical examination can be entirely normal in patients with large pericardial effusions if fluid accumulates slowly over days to weeks, allowing the pericardium to stretch without causing tamponade. 1 This contrasts sharply with rapid accumulation (trauma, iatrogenic perforation), where even small amounts of blood cause tamponade within minutes. 1

Do not rely solely on physical examination findings to exclude significant pericardial effusion—many patients are asymptomatic and effusion is discovered incidentally on imaging. 1, 4 The absence of classic tamponade signs does not rule out hemodynamically significant effusion requiring intervention.

Pericardial friction rubs are rarely heard in isolated effusion and their presence typically indicates concomitant inflammatory pericarditis rather than pure effusion. 1