A 67-year-old man with a 40-pack-year smoking history and severe chronic obstructive pulmonary disease presents to the clinic complaining of increasing lower extremity swelling, progressive fatigue, and abdominal fullness over the past month. He denies paroxysmal nocturnal dyspnea, orthopnea, or chest pain. Vital signs are temperature 37.1°C (98.8°F), blood pressure 118/76 mmHg, pulse 94/min, and respiratory rate 18/min. Pulse oximetry shows 89% on room air. The physician suspects cor pulmonale (isolated right-sided heart failure secondary to pulmonary disease). Which of the following physical examination findings are most consistent with this specific diagnosis? (Select exactly 2 options)
- A palpable left parasternal liftAnswer
- A tender, pulsatile liver edgeAnswer
- CBilateral fine, late-inspiratory crackles
- DA third heart sound (S3) best heard at the cardiac apex
- EA laterally displaced point of maximal impulse
Answer
The correct physical examination findings are a palpable left parasternal lift and a tender, pulsatile liver edge.
Cor pulmonale is defined as right ventricular hypertrophy and eventual right heart failure resulting from primary pulmonary disease (such as severe chronic obstructive pulmonary disease). As the right ventricle hypertrophies against elevated pulmonary artery pressures, it generates a palpable left parasternal lift (or heave). As the ventricle subsequently dilates and fails, the tricuspid annulus stretches, leading to secondary tricuspid regurgitation. The resulting retrograde transmission of venous pressure creates a tender, pulsatile liver edge. Both findings specifically localize the pathology to the right side of the heart, ruling out left ventricular involvement.
Step-by-Step Solution
Key Concept
Differentiating the physical examination findings of isolated right-sided heart failure (cor pulmonale) from left-sided or biventricular heart failure.