Auscultation noted irregular heartbeats, systolic murmur in the tricuspid area, splitting of the second heart sound with loud pulmonary valve closure sound in the pulmonary area. Pulmonary auscultation noted crepitation in lower third of both lung fields. Electrocardiogram noted atrial fibrillation with an irregular ventricular rate at 90 beats per minute, normal axis, microvoltage in peripheral leads and Q-wave couples with incomplete left bundle branch block in anteroseptal leads. Transthoracic echocardiography showed a large circumferential pericardial effusion measuring 15 mm at the lateral region of the right ventricle and 25-27 mm at the lateral region of the left ventricle. There was no hemodynamic consequence due to the effusion: both ventricles were neither dilated and nor dysfunctional, no significant variation in mitral or tricuspid inflow. Inferior vena cava measured 20 mm. There was mild left ventricular hypertrophy, moderate biatrial enlargement, severe tricuspid regurgitation and severe pulmonary hypertension.