Subjective
Date of visit
Reason for visit (initial presentation, follow-up)
History of present illness:
Chest pain (location, character, severity, radiation) – sharp, pleuritic pain may be present
Shortness of breath (especially on exertion)
Fatigue
Cough (may be productive)
Palpitations (awareness of heartbeat)
Recent illness or infection (if suspected to be a cause)
Past medical history of conditions that can cause pericardial effusion (e.g., autoimmune disease, malignancy)
Medications (current medications)
Allergies
Objective
Vital signs (temperature, heart rate, jugular venous distention [JVD] – elevated JVD may be present)
Physical exam:
General appearance (illness, respiratory distress)
Cardiovascular examination:
Heart sounds (muffled heart sounds due to fluid between the heart and pericardium)
Peripheral edema (fluid buildup in legs) – may be present in severe cases
Respiratory examination (rales – crackles in the lungs – may be present due to fluid overload)
Assessment
Pericardial effusion (suspected) based on clinical presentation and physical exam findings
Consider severity based on symptoms and hemodynamic status (stable vs. unstable)
Evaluate for potential causes of pericardial effusion:
Idiopathic (unknown cause)
Infectious (viral, bacterial)
Post-pericarditis (inflammation of the pericardium)
Autoimmune disease (e.g., lupus)
Malignancy (cancerous cells in the pericardium)
Uremia (waste products buildup in blood due to kidney failure)
Myocardial infarction (heart attack) – can cause pericardial effusion in some cases
Plan
Diagnostic testing:
Echocardiogram (ultrasound of the heart) – confirms the presence of effusion and assesses its severity
Chest X-ray (may show an enlarged cardiac silhouette)
Electrocardiogram (ECG) – may show electrical abnormalities
Blood tests (complete blood count, inflammatory markers, thyroid function tests, cardiac enzymes) to identify underlying cause
Pericardial fluid analysis (if performed) – to determine the cause of the effusion (e.g., cell count, protein levels)
Treatment:
Depends on the underlying cause and severity of the effusion
Diuretics (to remove excess fluid from the body)
Anti-inflammatory medications (e.g., NSAIDs, steroids) – to reduce inflammation in the pericardium
Antibiotics (if an infection is the cause)
Pericardiocentesis (removal of fluid from the pericardium with a needle) – may be necessary in severe cases or for diagnostic purposes
Follow-up
Schedule for next appointment:
Monitor response to treatment (symptom improvement, repeat echocardiogram)
Address the underlying cause (if identified)
Consider referral to a cardiologist for complex cases or if pericardiocentesis is needed
Note: This is a template and may need to be modified based on the individual patient’s presentation, severity of symptoms, and underlying cause of the pericardial effusion.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of pericardial effusion.