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Difficulty: MediumPhysical Examination Findings

A 42-year-old woman is brought to the emergency department complaining of sudden-onset, severe shortness of breath and progressive lightheadedness over the past 2 hours. She has a history of stage IV breast cancer and is currently undergoing chemotherapy. Her temperature is 37.1 C (98.8 F), blood pressure is 82/50 mm Hg, heart rate is 122/min, and respiratory rate is 26/min. Pulse oximetry is 94% on room air. Her extremities are cool and clammy. Which of the following physical examination findings are most likely to be present in this patient? (Select all that apply)

  1. Decrease in systolic blood pressure of greater than 10 mm Hg during inspirationAnswer
  2. Muffled or distant heart soundsAnswer
  3. C
    Elevated jugular venous pressure with a rapid y descent
  4. D
    Third heart sound (S3) gallop
  5. E
    Bilateral basilar crackles on lung auscultation

Answer

Decrease in systolic blood pressure of greater than 10 mm Hg during inspiration AND Muffled or distant heart sounds
The correct findings include a significant drop in systolic blood pressure during inspiration (pulsus paradoxus) and muffled heart sounds. This patient's history of metastatic breast cancer and acute presentation of obstructive shock are highly suspicious for malignant pericardial effusion causing cardiac tamponade. The increased intrapericardial pressure restricts diastolic filling, leading to decreased stroke volume and hypotension. Muffled heart sounds result from fluid accumulating around the heart, while pulsus paradoxus occurs due to bowing of the interventricular septum into the left ventricle during inspiration.

Step-by-Step Solution

1
Analyze the patient's presentation and history.
The patient has a history of malignancy, acute dyspnea, hypotension, and tachycardia.
Identifying key clinical features helps formulate a differential diagnosis for a shock state in an oncology patient.
2
Formulate the most likely diagnosis.
Malignant pericardial effusion leading to cardiac tamponade.
The combination of metastatic cancer, acute shock, and the nature of the acute presentation strongly points toward obstructive shock from tamponade.
3
Correlate the diagnosis with expected physical examination findings.
Cardiac tamponade typically presents with Beck's triad (hypotension, jugular venous distention, muffled heart sounds) and pulsus paradoxus.
Understanding the pathophysiology of impaired right ventricular filling dictates the expected clinical signs.

Key Concept

Physical examination findings in cardiac tamponade include Beck's triad (hypotension, jugular venous distention, and muffled heart sounds) and pulsus paradoxus (exaggerated inspiratory drop in systolic blood pressure).
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Physical Examination Findings

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