**4. Physical examination**

The physical examination of patient presented with myocarditis is frequently normal. Mild cases of patients with myocarditis may appear to have a simple viral syndrome. More acutely ill patients with acute myocarditis have the classic signs of circulatory impairment due to congestive heart failure. Patients may shows signs of fluid overload including elevated jugular venous pressure, bibasilar crackles, hepatomegaly, ascites and peripheral edema. More severe cases may show cardiovascular collapse and signs of shock. In addition to the signs of fluid overload, the physical examination may reveal direct evidence of cardiovascular signs in symptomatic patients. Tachypnea and tachycardia are common. Tachycardia is often out of proportion to fever. Cyanosis may occur as well. The apex beat may be diffuse and laterally displaced suggesting cardiomegaly. Heart auscultation may reveal diminished intensity of first heart sound. The third and occasionally fourth heart sound summation gallops may be noted with impaired ventricular function, particularly when biventricular acute myocardial involvement results in systemic and pulmonary congestion. If the right or left ventricular dilatation is severe, auscultation may reveal murmurs of mitral or tricuspid valves regurgitation. Table 1 summarized the most significant clinical manifestations and physical findings in patients presented with myocarditis.

A pericardial friction rub and effusion may become evident in some patients with diffuse inflammation as a result of myopericarditis. Pericardial tamponade was reported in very rare occasions. Pleural friction rub may develop as the inflammatory process involves surrounding structures. In cases where a dilated cardiomyopathy has developed, signs of peripheral or pulmonary thromboembolism may be encountered. Certain physical findings may imply a specific cause of myocarditis. Enlarged lymph nodes might suggest systemic sarcoidosis. A pruritic, maculopapular rash may suggest a hypersensitivity reaction, often to a drug or toxin. Acute rheumatic fever can present with the modified Jones criteria.
