Intended for healthcare professionals

Endgames Picture Quiz

Signs of shock and raised jugular venous pressure

BMJ 2012; 344 doi: (Published 20 April 2012) Cite this as: BMJ 2012;344:e2643
  1. Daniel Keene, foundation year 2 doctor1,
  2. Anjali Gopinath, foundation year 1 doctor1,
  3. William Watson, foundation year 1 doctor2,
  4. Clint Maart, cardiology registrar1,
  5. Awais Bokhari, consultant cardiologist1
  1. 1Cardiology Department, Bedford Hospital, Bedford MK42 9DJ, UK
  2. 2Cambridge University Hospital, Intensive Care, Cambridge, UK
  1. Correspondence to: D Keene drkeene{at}

A 38 year old white man presented to the emergency department with a three month history of progressively worsening shortness of breath. He had also experienced other vague symptoms over the same period, including muscle aches, weakness, pains associated with fatigue, and noticeable weight loss. Having previously been fit and well, he was now struggling to climb the stairs at home. The onset of symptoms coincided with an episode of food poisoning; he denied any recent travel.

On clinical examination he had quiet heart sounds, with a raised jugular venous pressure, which rose on inspiration. He showed signs of haemodynamic compromise and shock, with a heart rate of 115 beats/min, blood pressure of 105/75 mm Hg but no postural drop, respiratory rate of 24 breaths/min, and oxygen saturations of 95% on room air. Chest radiography (fig 1) and electrocardiography showed classic changes. The results of these investigations prompted immediate point of care transthoracic echocardiography (fig 2). After consent, he was promptly admitted to the cardiac catheterisation laboratory for immediate intervention.


  • 1 What abnormalities can be seen on the chest radiograph and echocardiogram?

  • 2 What clinical abnormality was suspected, and what are the classic electrocardiographic abnormalities seen with this condition?

  • 3 What is the most likely cause of this condition in this patient?

  • 4 What classic signs were elicited in this patient? What other sign might have been elicited to point towards the diagnosis?

  • 5 How should this patient be managed?


1 What abnormalities can be seen on the chest radiograph and echocardiogram?

Short answer

The chest radiograph shows a globular cardiac silhouette (fig 1), possibly as a result of fluid surrounding the heart. The echocardiogram shows a large pericardial effusion (fig 3).

Fig 3 Echocardiogram showing evidence of a pericardial effusion …

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