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{{SI}}
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{{CMG}}; {{AE}} {{JS}}
==Overview==
The '''pericardial friction rub''', also '''pericardial rub''', is a [[Medical sign|sign]] on the [[precordial exam]], detected by [[auscultation]], that suggests irritation of the [[pericardium]] and the diagnosis of [[pericarditis]]. 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 is often loud and 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, more specifically: [[Cardiac cycle|atrial systole]], [[Cardiac cycle|rapid-filling phase of the ventricle]] and [[Cardiac cycle|ventricular systole]]. A one-component rub, usually during ventricular systole, is suggestive of [[myopericarditis]] following [[ST elevation myocardial infarction|transmural myocardial infarction]].


{{Editor Help}}
==Causes==
===Life Threatening Causes===
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.


==Overview==
*[[Cardiac tamponade]]
The '''pericardial friction rub''', also '''pericardial rub''', is a [[Medical sign|sign]] on the [[precordial exam]], detected by [[auscultation]], that suggests irritation of the [[pericardium]] and the diagnosis of [[pericarditis]]. 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 seems very close to the ear and 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.
*[[Myocardial infarction]]


== Differential Diagnosis ==
===Common Causes===
<ref>Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016</ref> <ref>Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X</ref>


In alphabetical order. <ref>Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016</ref> <ref>Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X</ref>
*[[Amyloidosis]]
*[[Cardiac tamponade]]
*[[Collagen vascular disease]]
*[[Dressler's syndrome]]
*[[Familial mediterranean fever]]
*[[HIV]]
*[[Leukemia|Leukemic infiltration]]
*[[Radiation therapy|Mediastinal  radiation]]
*[[Mediastinal emphysema]]
*[[STEMI|Myocardial infarction]]
*[[Myocarditis]]
*[[Neoplasm]]
*[[Human parasitic diseases|Parasitic infection]]
*[[Pleural friction rub|Pleuropericardial rub]]
*[[Pericarditis]]
*[[Rheumatic fever]]
*[[Sarcoidosis]]
*[[Ebstein's anomaly of the tricuspid valve|Sail sound of ebstein's anomaly]]
*[[Thyrotoxicosis]]
*[[Toxoplasmosis]]
*[[Trauma]]
*[[Tuberculosis]]
*[[Uremia]]
*[[Viral]]
 
===Causes by Organ System===
{|style="width:80%; height:100px" border="1"
|style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" |'''Cardiovascular'''
|style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | [[Pneumomediastinum|Acute  mediastinal emphysema]], [[cardiac tamponade]], [[collagen vascular disease]], [[dilated cardiomyopathy]], [[dissecting aortic aneurysm]], [[Dressler's syndrome]], [[heart surgery]], [[mediastinal emphysema]], [[myocardial infarction]], [[myocardial rupture]], [[myocarditis]], [[myxedema]], [[neoplasm]], [[parasitic infection]], [[pericarditis]], [[pleural friction rub|pleuropericardial  rub]], [[rheumatic fever]], [[Ebstein's anomaly of the tricuspid valve|sail  sound of ebstein's anomaly]], [[sarcoidosis]], [[scrub typhus]], [[thyrotoxicosis]], [[toxoplasmosis]], [[ventricular aneurysm]], [[viral]]
|-
|bgcolor="LightSteelBlue"| '''Chemical/Poisoning'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Dental'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Dermatologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Drug Side Effect'''
|bgcolor="Beige"|  [[Cytarabine]], [[Procainamide]]
|-
|-bgcolor="LightSteelBlue"
| '''Ear Nose Throat'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Endocrine'''
|bgcolor="Beige"| [[Hypothyroidism]], [[myxedema]], [[thyrotoxicosis]]
|-
|-bgcolor="LightSteelBlue"
| '''Environmental'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Gastroenterologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Genetic'''
|bgcolor="Beige"| [[Amyloidosis]], [[bronchogenic cyst]], [[collagen vascular disease]], [[dilated cardiomyopathy]], [[dissecting aortic aneurysm]], [[familial mediterranean fever]], [[hypothyroidism]], [[Ebstein's anomaly of the tricuspid valve|sail  sound of ebstein's anomaly]], [[ventricular aneurysm]]
|-
|-bgcolor="LightSteelBlue"
| '''Hematologic'''
|bgcolor="Beige"| [[Leukemia|Leukemic infiltration]]
|-
|-bgcolor="LightSteelBlue"
| '''Iatrogenic'''
|bgcolor="Beige"| [[Balloon catheter|Balloon  flotation catheter]], [[heart surgery]], [[complications during and following cardiac catheterization|inadvertent  entry of air into the right ventricular cavity]], [[radiation therapy|mediastinal  radiation]], [[procainamide]], [[transvenous pacing|transvenous pacing catheter]], [[the EKG in a patient with a pacemaker|twitching  of the intercostal muscles or of the diaphragm during artificial pacing]]
|-
|-bgcolor="LightSteelBlue"
| '''Infectious Disease'''
|bgcolor="Beige"| [[HIV]], [[mycobacterium tuberculosis]], [[myocarditis]], [[parasitic infection]], [[pericarditis]], [[rheumatic fever]], [[scrub typhus]], [[toxoplasmosis]], [[tuberculosis]], [[viral]]
|-
|-bgcolor="LightSteelBlue"
| '''Musculoskeletal/Orthopedic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Neurologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Nutritional/Metabolic'''
|bgcolor="Beige"| [[Uremia]]
|-
|-bgcolor="LightSteelBlue"
| '''Obstetric/Gynecologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Oncologic'''
|bgcolor="Beige"| [[leukemia|Leukemic infiltration]], [[neoplasm]]
|-
|-bgcolor="LightSteelBlue"
| '''Ophthalmologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Overdose/Toxicity'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Psychiatric'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Pulmonary'''
|bgcolor="Beige"| [[Pneumomediastinum|Acute mediastinal emphysema]], [[pleural friction rub|pleuropericardial rub]]
|-
|-bgcolor="LightSteelBlue"
| '''Renal/Electrolyte'''
|bgcolor="Beige"| [[Uremia]]
|-
|-bgcolor="LightSteelBlue"
| '''Rheumatology/Immunology/Allergy'''
|bgcolor="Beige"| [[Dressler's syndrome]], [[familial mediterranean fever]], [[rheumatic fever]], [[sarcoidosis]]
|-
|-bgcolor="LightSteelBlue"
| '''Sexual'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Trauma'''
|bgcolor="Beige"| [[Dissecting aortic aneurysm]], [[Dressler's syndrome]], [[trauma]]
|-
|-bgcolor="LightSteelBlue"
| '''Urologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Miscellaneous'''
|bgcolor="Beige"| [[Swallowing|Swallowing sounds]]
|-
|}


===Causes in Alphabetical Order===
{{col-begin|width=80%}}
{{col-break|width=33%}}
*[[Pneumomediastinum|Acute  mediastinal emphysema]]
*[[Amyloidosis]]
*[[Amyloidosis]]
*[[Cardiac tamponade]]
*[[Balloon catheter|Balloon  flotation catheter]]
*[[Collagen Vascular Disease]]
*[[Bronchogenic  cyst]]
*[[Familial Mediterranean Fever]]
*[[Cardiac tamponade]]
*[[Collagen vascular disease]]
*[[Cytarabine]]
*[[Dilated  cardiomyopathy]]
*[[Dissecting  aortic aneurysm]]
*[[Dressler's  syndrome]]
*[[Familial mediterranean fever]]
*[[Heart  surgery]]
*[[HIV]]
*[[HIV]]
*[[Ischemia]]
*[[Hypothyroidism]]
*Leukemic infiltration
*[[Complications during and following cardiac catheterization|Inadvertent  entry of air into the right ventricular cavity]]
*Mediastinal [[radiation]]
*[[Leukemia|Leukemic infiltration]]
*Mediastinal emphysema
 
*[[STEMI|Acute Myocardial Infarction]]
 
{{col-break|width=33%}}
*[[Mediastinal emphysema]]
*[[Radiation therapy|Mediastinal  radiation]]
*[[Mycobacterium  tuberculosis]]
*[[Myocardial  infarction]]
*[[Myocardial rupture]]
*[[Myocarditis]]
*[[Myocarditis]]
*[[Myxedema]]
*[[Neoplasm]]
*[[Neoplasm]]
*Parasitic infection
*[[Parasitic infection]]
*Pleuropericardial rub
*[[Pulmonary Embolism]]
*[[Pericarditis]]
*[[Pericarditis]]
*[[Rheumatic Fever]]
*[[Pleural friction rub|Pleuropericardial  rub]]
*[[Procainamide]]
*[[Rheumatic fever]]
*[[Ebstein's anomaly of the tricuspid valve|Sail  sound of ebstein's anomaly]]
*[[Sarcoidosis]]
*[[Sarcoidosis]]
*Sail sound of [[Ebstein's anomaly]]
{{col-break|width=33%}}
*[[Scrub  typhus]]
*[[Swallowing|Swallowing  sounds]]
*[[Thyrotoxicosis]]
*[[Thyrotoxicosis]]
*[[Toxoplasmosis]]
*[[Toxoplasmosis]]
*[[Transvenous pacing|Transvenous  pacing catheter]]
*[[Trauma]]
*[[Trauma]]
*[[Tuberculosis]]
*[[Tuberculosis]]
*[[The EKG in a patient with a pacemaker|Twitching  of the intercostal muscles or of the diaphragm during artificial pacing]]
*[[Uremia]]
*[[Uremia]]
*[[Ventricular  aneurysm]]
*[[Viral]]
*[[Viral]]
{{col-end}}


== Diagnosis ==  
== Diagnosis ==  


=== History and Symptoms ===  
=== History and Symptoms ===  
*History includes:
History includes:
:*Family
*Recent bacterial infection
:*Personal
*[[Tuberculosis]]
:*exposures
*Recent viral exposure
:*recent viral exposure
*[[Autoimmunity|Autoimmune disease]]
:*fever
*[[Fever]]
:*trauma
*[[ST elevation myocardial infarction|Myocardial infarction]]
*Exaggerated pulsus paradoxus
*Pericardiotomy
*[[Uremia]]
*Trauma
 
===Physical Examination===
Considering that several causes, mentioned above, can be responsible for the presence of a pericardial rub on auscultation, a full physical exam should be performed, in order to gather every sign, for appropriate differential diagnosis.
A careful exam should be conducted to evaluate the patient for signs of life-threatening situations, such as [[cardiac tamponade]].
Pericardial rubs are best heard with the diaphragm of the stethoscope, and can be described according to:<ref>{{Cite book  | last1 = Bickley | first1 = Lynn S. | last2 = Szilagyi | first2 = Peter G. | last3 = Bates | first3 = Barbara | author3-link = Barbara Bates | title = Bates' guide to physical examination and history taki | date = 2009 | publisher = Wolters Kluwer Health/Lippincott Williams  Wilkins | location = Philadelphia | isbn = 0-7817-8058-6 | pages =  }}</ref>
*Location: although variable, it is usually best heard in the 3rd interspace to the left of the sternum;
*Radiation: little;
*Intensity: although variable, it may increase with the patient leaning forward, when exhaling or holding breath (contrast with pleural rub);
*Quality: scratching and grating;
*Pitch: high
The pericardial rub sound usually varies in intensity over time, therefore auscultation should be performed at several occasions.<ref name="pmid20511488">Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM et al. (2010) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=20511488 Pericardial disease: diagnosis and management.] ''Mayo Clin Proc'' 85 (6):572-93. [http://dx.doi.org/10.4065/mcp.2010.0046 DOI:10.4065/mcp.2010.0046] PMID: [http://pubmed.gov/20511488 20511488]</ref>
 
 
'''Below is the video demonstrating Pericardial friction rub:'''
 
{{#ev:youtube|EUCp_3_vwtw}}


=== Laboratory Findings ===  
=== Laboratory Findings ===  
Line 76: Line 248:


=== Electrocardiogram ===  
=== Electrocardiogram ===  
*[[ECG]] for potential [[MI]], [[pericarditis]] or other cardiac problems
[[ECG]] for potential [[MI]], [[pericarditis]] or other cardiac problems


=== Chest X Ray ===  
=== Chest X Ray ===  
*[[Cardiomegaly]]
Depending upon the underlying cause and if an effusion is present, the [[chest x-ray]] may show signs of [[cardiomegaly]]


=== Echocardiography or Ultrasound ===  
=== Echocardiography or Ultrasound ===  
*Echo for [[pleural effusion]]
If there is a clinical suspicion of [[cardiac tamponade]], and [[echocardiography|echocardiogram]] should be performed to assess the size of the effusion, to guide [[pericardiocentesis]].
:*[[valve problems]]
 
:*[[atrial septal defect]]s
=== Cardiac Computed Tomography and Cardiac Magnetic Resonance ===
:*[[ventricular septal defect]]s
Cardiac Computed Tomography and Cardiac Magnetic Resonance are gaining more importance in the diagnosis of pericarditis. Both are very sensitive methods in diagnosing effusions, as well as in determining pericardial thickness.<ref name="pmid20511488">Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM et al. (2010) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=20511488 Pericardial disease: diagnosis and management.] ''Mayo Clin Proc'' 85 (6):572-93. [http://dx.doi.org/10.4065/mcp.2010.0046 DOI:10.4065/mcp.2010.0046] PMID: [http://pubmed.gov/20511488 20511488]</ref>


== Treatment ==
== Treatment ==
Line 96: Line 268:


=== Indications for Surgery ===  
=== Indications for Surgery ===  
*Emergency [[pericardiocentesis]] to drain effusions of the [[pericardium]] in [[cardiac tamponade]]
An emergency [[pericardiocentesis]] is indicated in the presence of [[cardiac tamponade]], a large symptomatic [[pericardial effusion]], or to establish the diagnosis in a case of suspected [[Pericarditis in malignancy|malignant]] or [[tuberculous pericarditis]].


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
==See also==
*[[Precordial exam]]




{{Electrocardiography}}
{{Electrocardiography}}
{{Circulatory system pathology}}
{{Circulatory system pathology}}
{{SIB}}
 




[[Category:Cardiology]]
[[Category:Cardiology]]
[[Category:Medical signs]]
[[Category:Signs and symptoms]]
[[Category:Signs and symptoms]]
[[Category:Physical examination]]
[[Category:Physical examination]]
Line 113: Line 289:
{{WikiDoc Help Menu}}
{{WikiDoc Help Menu}}
{{WikiDoc Sources}}
{{WikiDoc Sources}}
==See also==
*[[Precordial exam]]
{{SIB}}
[[Category:Cardiology]]
[[Category:Signs and symptoms]]
{{WH}}
{{WS}}

Latest revision as of 12:25, 12 June 2015

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2]

Overview

The pericardial friction rub, also pericardial rub, is a sign on the precordial exam, detected by auscultation, that suggests irritation of the pericardium and the diagnosis of pericarditis. 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 is often loud and 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, more specifically: atrial systole, rapid-filling phase of the ventricle and ventricular systole. A one-component rub, usually during ventricular systole, is suggestive of myopericarditis following transmural myocardial infarction.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

[1] [2]

Causes by Organ System

Cardiovascular Acute mediastinal emphysema, cardiac tamponade, collagen vascular disease, dilated cardiomyopathy, dissecting aortic aneurysm, Dressler's syndrome, heart surgery, mediastinal emphysema, myocardial infarction, myocardial rupture, myocarditis, myxedema, neoplasm, parasitic infection, pericarditis, pleuropericardial rub, rheumatic fever, sail sound of ebstein's anomaly, sarcoidosis, scrub typhus, thyrotoxicosis, toxoplasmosis, ventricular aneurysm, viral
Chemical/Poisoning No underlying causes
Dental No underlying causes
Dermatologic No underlying causes
Drug Side Effect Cytarabine, Procainamide
Ear Nose Throat No underlying causes
Endocrine Hypothyroidism, myxedema, thyrotoxicosis
Environmental No underlying causes
Gastroenterologic No underlying causes
Genetic Amyloidosis, bronchogenic cyst, collagen vascular disease, dilated cardiomyopathy, dissecting aortic aneurysm, familial mediterranean fever, hypothyroidism, sail sound of ebstein's anomaly, ventricular aneurysm
Hematologic Leukemic infiltration
Iatrogenic Balloon flotation catheter, heart surgery, inadvertent entry of air into the right ventricular cavity, mediastinal radiation, procainamide, transvenous pacing catheter, twitching of the intercostal muscles or of the diaphragm during artificial pacing
Infectious Disease HIV, mycobacterium tuberculosis, myocarditis, parasitic infection, pericarditis, rheumatic fever, scrub typhus, toxoplasmosis, tuberculosis, viral
Musculoskeletal/Orthopedic No underlying causes
Neurologic No underlying causes
Nutritional/Metabolic Uremia
Obstetric/Gynecologic No underlying causes
Oncologic Leukemic infiltration, neoplasm
Ophthalmologic No underlying causes
Overdose/Toxicity No underlying causes
Psychiatric No underlying causes
Pulmonary Acute mediastinal emphysema, pleuropericardial rub
Renal/Electrolyte Uremia
Rheumatology/Immunology/Allergy Dressler's syndrome, familial mediterranean fever, rheumatic fever, sarcoidosis
Sexual No underlying causes
Trauma Dissecting aortic aneurysm, Dressler's syndrome, trauma
Urologic No underlying causes
Miscellaneous Swallowing sounds

Causes in Alphabetical Order

Diagnosis

History and Symptoms

History includes:

Physical Examination

Considering that several causes, mentioned above, can be responsible for the presence of a pericardial rub on auscultation, a full physical exam should be performed, in order to gather every sign, for appropriate differential diagnosis. A careful exam should be conducted to evaluate the patient for signs of life-threatening situations, such as cardiac tamponade. Pericardial rubs are best heard with the diaphragm of the stethoscope, and can be described according to:[3]

  • Location: although variable, it is usually best heard in the 3rd interspace to the left of the sternum;
  • Radiation: little;
  • Intensity: although variable, it may increase with the patient leaning forward, when exhaling or holding breath (contrast with pleural rub);
  • Quality: scratching and grating;
  • Pitch: high

The pericardial rub sound usually varies in intensity over time, therefore auscultation should be performed at several occasions.[4]


Below is the video demonstrating Pericardial friction rub:

{{#ev:youtube|EUCp_3_vwtw}}

Laboratory Findings

  • Labs include:

Electrocardiogram

ECG for potential MI, pericarditis or other cardiac problems

Chest X Ray

Depending upon the underlying cause and if an effusion is present, the chest x-ray may show signs of cardiomegaly

Echocardiography or Ultrasound

If there is a clinical suspicion of cardiac tamponade, and echocardiogram should be performed to assess the size of the effusion, to guide pericardiocentesis.

Cardiac Computed Tomography and Cardiac Magnetic Resonance

Cardiac Computed Tomography and Cardiac Magnetic Resonance are gaining more importance in the diagnosis of pericarditis. Both are very sensitive methods in diagnosing effusions, as well as in determining pericardial thickness.[4]

Treatment

  • Hemodynamic stability is intact
  • Supplemental oxygen

Acute Pharmacotherapies

Indications for Surgery

An emergency pericardiocentesis is indicated in the presence of cardiac tamponade, a large symptomatic pericardial effusion, or to establish the diagnosis in a case of suspected malignant or tuberculous pericarditis.

References

  1. ↑ Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016
  2. ↑ Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X
  3. ↑ Bickley, Lynn S.; Szilagyi, Peter G.; Bates, Barbara (2009). Bates' guide to physical examination and history taki. Philadelphia: Wolters Kluwer Health/Lippincott Williams Wilkins. ISBN 0-7817-8058-6.
  4. ↑ 4.0 4.1 Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM et al. (2010) Pericardial disease: diagnosis and management. Mayo Clin Proc 85 (6):572-93. DOI:10.4065/mcp.2010.0046 PMID: 20511488

See also



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