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Difficulty: EasyPhysical Examination Findings

A 32-year-old woman with a history of systemic lupus erythematosus presents to the emergency department complaining of severe shortness of breath and sharp chest pain that worsens when she lies flat. Her temperature is 37.8°C (100.0°F), blood pressure is 86/48 mm Hg, and pulse is 124/min. The physician strongly suspects acute cardiac tamponade secondary to a pericardial effusion. Based on this suspected diagnosis, which of the following physical examination findings would most likely be present? (Select exactly two)

  1. A decrease in systolic blood pressure of greater than 10 mm Hg during inspirationAnswer
  2. Distant, muffled heart sounds on precordial auscultationAnswer
  3. C
    A prominent 'y' descent on the jugular venous pressure waveform
  4. D
    Bilateral fine inspiratory crackles at the lung bases
  5. E
    Displacement of the point of maximal impulse laterally to the anterior axillary line

Answer

The correct findings are a decrease in systolic blood pressure of greater than 10 mm Hg during inspiration (pulsus paradoxus) and distant, muffled heart sounds.
Cardiac tamponade restricts cardiac filling due to fluid accumulation in the rigid pericardial space. This results in Beck's triad: systemic hypotension, elevated jugular venous pressure, and muffled or distant heart sounds (because the fluid insulates the acoustic transmission). Furthermore, the fixed pericardial volume enhances ventricular interdependence; during inspiration, increased venous return to the right ventricle causes the interventricular septum to bow into the left ventricle. This decreases left ventricular stroke volume, leading to a drop in systolic blood pressure of > 10 mm Hg during inspiration (pulsus paradoxus).

Step-by-Step Solution

1
Identify the suspected diagnosis based on the clinical vignette.
The patient is hypotensive, tachycardic, and has a strong suspicion of acute cardiac tamponade due to pericardial effusion.
Establishing the underlying condition is required to deduce the expected physical examination signs.
2
Recall the classic physical examination findings associated with cardiac tamponade.
Findings include Beck's triad (hypotension, jugular venous distention, muffled heart sounds) and pulsus paradoxus.
These signs are direct results of fluid in the pericardial sac restricting ventricular filling and causing exaggerated ventricular interdependence.
3
Evaluate the answer choices to identify the findings that match the suspected pathophysiology.
Pulsus paradoxus and muffled heart sounds correctly identify the hemodynamic consequences of tamponade. The other options indicate different conditions like constrictive pericarditis or dilated cardiomyopathy.
Differentiating these physical signs is crucial for confirming the diagnosis at the bedside.

Key Concept

Physical examination findings in cardiac tamponade (Beck's triad and pulsus paradoxus)
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Physical Examination Findings

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