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Difficulty: HardPhysical Examination Findings

A 52-year-old woman is evaluated in the clinic for a 4-month history of progressive fatigue, abdominal fullness, and bilateral lower extremity swelling. She has no chest pain, orthopnea, or paroxysmal nocturnal dyspnea. Medical history is significant for Hodgkin lymphoma diagnosed at age 28, for which she was treated with systemic chemotherapy and mantle field radiation therapy. Vital signs show a temperature of 37.0°C (98.6°F), blood pressure of 112/76 mm Hg, heart rate of 88/min, and respiratory rate of 16/min. The lungs are clear to auscultation bilaterally. Abdominal examination reveals shifting dullness and a liver edge palpable 4 cm below the right costal margin. Bilateral 2+ pitting edema is present up to the knees. Which of the following physical examination findings are most likely to be present in this patient? (Select all that apply)

  1. A paradoxical rise in jugular venous pressure during inspirationAnswer
  2. A sharp, high-frequency early diastolic sound heard best along the left sternal borderAnswer
  3. C
    A decrease in systolic blood pressure of greater than 15 mm Hg during normal inspiration
  4. D
    An absent y-descent on the jugular venous waveform
  5. E
    A laterally displaced point of maximal impulse with a third heart sound (S3)

Answer

The correct findings include a paradoxical rise in jugular venous pressure during inspiration (Kussmaul sign) and a sharp, early diastolic sound (pericardial knock).
This patient's presentation of progressive right-sided heart failure (ascites, hepatomegaly, peripheral edema) in the absence of left-sided heart failure (clear lungs, no orthopnea), combined with a remote history of thoracic radiation therapy, is highly suggestive of constrictive pericarditis. Radiation causes chronic inflammation leading to a fibrotic, thickened, and calcified pericardium. The rigid pericardium restricts diastolic filling of the heart. During inspiration, the increased venous return to the right heart cannot be accommodated, leading to a paradoxical rise in jugular venous pressure (Kussmaul sign). Additionally, the sudden halt in early diastolic ventricular filling caused by the rigid pericardium produces a high-frequency, early diastolic sound known as a pericardial knock.

Step-by-Step Solution

1
Analyze the patient's presentation and medical history.
The patient has isolated right-sided heart failure (ascites, hepatomegaly, peripheral edema, clear lungs) and a history of mantle field radiation therapy 24 years ago.
Identifying the clinical syndrome and primary risk factor focuses the differential diagnosis.
2
Determine the most likely underlying diagnosis based on the analysis.
Radiation-induced constrictive pericarditis.
Mantle field radiation is a classic cause of late-onset constrictive pericarditis, which presents chronically with signs of severe right heart failure and restricted ventricular filling.
3
Identify the physical examination findings pathognomonic for this specific condition.
Kussmaul sign (inspiratory rise in JVP) and a pericardial knock (early diastolic sound) are expected.
These findings reflect the pathophysiology of a rigid, non-compliant pericardial sac that limits diastolic expansion of the heart.

Key Concept

Late-onset constrictive pericarditis secondary to radiation therapy presents with right heart failure signs, Kussmaul sign, a pericardial knock, and a prominent y-descent on jugular venous tracing.
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Physical Examination Findings

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