🔹 Ewart’s Sign
✅ Definition: Ewart’s sign is a clinical finding in large pericardial effusion caused by compression of the left lower lobe of the lung by an enlarged pericardial sac.
Clinical Features of Ewart’s Sign
Percussion: Dullness at the left scapular angle (below the angle of the scapula).
Auscultation:
Bronchial breathing (due to compression of lung tissue)
Egophony (nasal quality of voice sounds)
Sometimes diminished breath sounds.
Mechanism
Large pericardial effusion → distended pericardial sac → compresses adjacent left lower lobe → produces findings resembling consolidation in that region.
Clinical Importance
Classical, though rarely encountered today (as large effusions are usually diagnosed earlier by echocardiography).
Ewart’s sign = suggestive of massive pericardial effusion.
🔑 Exam Pearl: 👉 Ewart’s sign = Dullness + Bronchial breathing + Egophony below left scapula → due to large pericardial effusion.
Q1. Ewart’s sign is seen in:
Large pericardial effusion
Pleural effusion
Pneumothorax
Constrictive pericarditis
Ewart’s sign is due to lung compression by a large pericardial effusion.
Q2. Which finding is part of Ewart’s sign?
Hyper-resonant percussion note
Dullness below the left scapula
Widened mediastinum
Crackles at lung bases
Percussion dullness at the left scapular angle is a key component of Ewart’s sign.
Q3. Beck’s triad in cardiac tamponade includes all EXCEPT:
Hypotension
Muffled heart sounds
Bounding pulses
Raised JVP
Beck’s triad = hypotension + muffled heart sounds + raised JVP.
Q4. The pathophysiological cause of Ewart’s sign is:
Pericardial calcification
Compression of left lower lobe by effusion
Right atrial collapse
Aortic root dilation
Large effusion compresses the left lower lobe, causing bronchial breath sounds and dullness.
Q5. Which clinical finding is most suggestive of cardiac tamponade?
Fixed splitting of S2
Pulsus paradoxus
Loud P2
S3 gallop
Pulsus paradoxus (>10 mmHg inspiratory fall in systolic BP) is strongly suggestive of tamponade.
Q6. Bronchial breathing at the left scapular angle is a feature of:
Ewart’s sign
Hamman’s sign
Kussmaul’s sign
Broadbent’s sign
Bronchial breathing in the left infrascapular region is part of Ewart’s sign.
Q7. Raised JVP with absent y-descent is most typical of:
Right heart failure
Cardiac tamponade
Constrictive pericarditis
Pulmonary embolism
Tamponade causes absent y-descent due to impaired ventricular filling.
Q8. Ewart’s sign is best elicited in which clinical position?
Supine
Sitting forward
Left lateral decubitus
Standing upright
With the patient sitting forward, percussion and auscultation over left lower lung are clearer.
Q9. Which of the following is NOT a sign of large pericardial effusion?
Soft, distant heart sounds
Ewart’s sign
Prominent apical impulse
Globular cardiac silhouette
Large effusion dampens apical impulse rather than making it prominent.
Q10. The triad of hypotension, muffled heart sounds, and raised JVP is known as:
Beck’s triad
Ewart’s sign
Kussmaul’s sign
Hamman’s sign
Beck’s triad is classic for cardiac tamponade.
1. Ewart’s sign is classically associated with:
A) Large pericardial effusion
B) Pleural effusion
C) Consolidation of left lower lobe
D) Aortic aneurysm
Ewart’s sign occurs due to compression of the left lower lobe by a massively distended pericardial sac.
2. Which finding is typical in Ewart’s sign?
A) Vesicular breath sounds
B) Bronchial breathing below the left scapula
C) Dull percussion over right lung base
D) Hyperresonant percussion over left chest
Bronchial breathing, dullness, and egophony below the left scapula indicate Ewart’s sign.
3. Beck’s triad in cardiac tamponade does NOT include:
A) Hypotension
B) Elevated JVP
C) Pulmonary crepitations
D) Muffled heart sounds
Beck’s triad = Hypotension + Elevated JVP + Muffled heart sounds.
4. Which bedside sign suggests pulsus paradoxus in tamponade?
A) Fall in systolic BP >10 mmHg on inspiration
B) Rise in systolic BP during inspiration
C) Fixed split of S2
D) Loud P2
Pulsus paradoxus = >10 mmHg fall in systolic BP on inspiration, classically in tamponade.
5. Kussmaul’s sign is defined as:
A) Fall of JVP on inspiration
B) Rise of JVP on inspiration
C) Disappearance of pulse on inspiration
D) Fall of BP on standing
Kussmaul’s sign = paradoxical rise in JVP on inspiration, seen in constriction and effusive-constrictive states.
6. In large pericardial effusion, heart sounds are usually:
A) Accentuated
B) Muffled
C) Splitting of S2
D) Presence of ejection click
Large pericardial effusion dampens heart sounds due to fluid insulation.
7. The “water bottle shaped heart” on chest X-ray suggests:
A) Large pericardial effusion
B) Pleural effusion
C) Cardiomyopathy
D) Left atrial enlargement
Globular “water bottle” shaped heart is a classic sign of large pericardial effusion.
8. Swinging heart on echocardiography is seen in:
A) Large pericardial effusion
B) Hypertrophic cardiomyopathy
C) Dilated cardiomyopathy
D) Aortic stenosis
Swinging motion of the heart is seen when it floats in large effusions.
9. The classical auscultatory finding in acute pericarditis is:
A) Pericardial friction rub
B) Loud S3
C) Opening snap
D) Continuous murmur
Pericardial friction rub is high-pitched and scratchy, heard best at left sternal border.
10. Which sign is most specific for cardiac tamponade?
A) Right atrial or RV diastolic collapse on echocardiography
B) Elevated JVP
C) Tachycardia
D) Hypotension
Echocardiographic collapse of RA or RV in diastole is highly specific for tamponade.
Clinical Signs of Pericardial Effusion & Cardiac Tamponade
Sign Finding Mechanism / Clinical Importance Ewart’s Sign Dullness on percussion + bronchial breathing + egophony below left scapula Compression of left lower lobe by large pericardial effusion Beck’s Triad Hypotension + Raised JVP + Muffled heart sounds Classical triad of cardiac tamponade Kussmaul’s Sign Raised JVP with inspiration Seen in constrictive pericarditis (not typical of tamponade) Pulsus Paradoxus >10 mmHg fall in systolic BP during inspiration Classic sign of tamponade Swinging Heart Electrical alternans on ECG Heart swings in large effusion Muffled Heart Sounds Soft, distant heart sounds Fluid insulates sound transmission Pericardial Rub Scratchy, triphasic sound (systolic + 2 diastolic components) Seen in pericarditis; may disappear with large effusion Raised JVP Prominent neck vein distension Impaired right heart filling Tachycardia Rapid heart rate Compensatory response to reduced stroke volume Dyspnea / Orthopnea Shortness of breath, worse on lying down Reduced ventricular filling + pulmonary venous congestion
Pericardial effusion imaging,,Echocardiography in pericardial effusion,,CT scan pericardial effusion,,MRI pericardial effusion,,Chest X-ray pericardial effusion,,Cardiac tamponade echocardiography,,Right ventricular collapse echo,,Swinging heart pericardial effusion,,Water bottle heart chest X-ray,,Loculated pericardial effusion imaging,,,Echo findings in pericardial effusion,,Doppler signs of tamponade,,Pericardial effusion diagnostic modalities,,MRI pericardial inflammation,,CT pericardial calcification,,Pericardial cyst vs effusion imaging,,Dilated IVC pericardial effusion,,Beck’s triad imaging correlation,,Hemorrhagic pericardial effusion MRI,,Imaging of pericardial diseases,,,Best imaging modality for pericardial effusion,,Echocardiography signs of cardiac tamponade,,Role of CT and MRI in pericardial effusion,,Chest X-ray features of pericardial effusion,,Minimum volume of fluid detected by echocardiography,,Differentiating pericardial effusion from pericardial cyst,,MRI tissue characterization in pericardial disease,,CT detection of loculated pericardial effusion,,Imaging approach in pericardial effusion and tamponade,,Echo-guided pericardiocentesis