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Difficulty: Very hardPhysical Examination Findings

A 61-year-old woman is evaluated in a hepatology clinic for progressive abdominal swelling and early satiety over the past three months. She also reports worsening bilateral lower extremity edema and exertional fatigue. Her medical history is significant for Hodgkin lymphoma diagnosed at age 25, which was treated with mantle field radiation and multi-agent chemotherapy. She takes no medications and does not consume alcohol. Vital signs are temperature 37.0°C (98.6°F), blood pressure 110/70 mm Hg, heart rate 88/min, and respiratory rate 16/min. Abdominal ultrasound demonstrates a nodular liver, moderate ascites, and splenomegaly, with normal hepatic vein Doppler flow. Based on the most likely underlying etiology of her symptoms, which of the following physical examination findings are expected in this patient? (Select 3 that apply)

  1. A paradoxical increase in jugular venous pressure during inspirationAnswer
  2. B
    An inspiratory decrease in systolic blood pressure of 18 mm Hg
  3. A prominent, steep 'y' descent visualized on the jugular venous waveformAnswer
  4. An early diastolic, high-frequency sound heard best at the left lower sternal borderAnswer
  5. E
    A laterally displaced, diffuse, and sustained apical impulse

Answer

The expected physical examination findings are a paradoxical increase in jugular venous pressure during inspiration (Kussmaul sign), a prominent, steep 'y' descent on the jugular venous waveform, and an early diastolic high-frequency sound (pericardial knock).
This patient's clinical picture of right-sided heart failure (ascites, hepatomegaly, pedal edema) decades after receiving mantle field radiation is highly characteristic of radiation-induced constrictive pericarditis. In this condition, the fibrotic and calcified pericardium creates a rigid shell around the heart. This restricts late diastolic filling while allowing rapid early diastolic filling due to elevated venous pressures. The rapid early emptying of the right atrium produces a steep 'y' descent on the jugular venous pulse (Friedreich sign). As the rapidly filling ventricle reaches the physical limit of the rigid pericardium, filling abruptly stops, producing an early diastolic sound known as a pericardial knock. Furthermore, because the rigid pericardium prevents the right ventricle from expanding to accommodate the normal increase in venous return during inspiration, venous blood backs up into the jugular veins, causing a paradoxical inspiratory rise in jugular venous pressure known as Kussmaul sign.

Step-by-Step Solution

1
Analyze the patient's presenting symptoms and initial workup.
The patient has ascites, edema, hepatomegaly, and a nodular liver, which initially suggests cirrhosis. However, the normal hepatic vein Doppler and history of radiation suggest a post-hepatic (cardiac) etiology causing 'cardiac cirrhosis'.
Differentiating primary hepatic disease from right-sided heart failure is the critical first step in determining the underlying pathophysiology.
2
Identify the specific cardiac pathology based on the medical history.
The patient had mantle field radiation for Hodgkin lymphoma 36 years ago. This strongly predisposes her to late-onset radiation-induced constrictive pericarditis.
Mantle field radiation has known long-term toxicities, predominantly affecting the pericardium, myocardium, and heart valves, leading to a rigid, fibrotic pericardium.
3
Correlate the diagnosis of constrictive pericarditis with its hemodynamic effects.
Constrictive pericarditis results in impaired late diastolic filling, rapid early diastolic filling, and isolation of the cardiac chambers from intrathoracic pressure changes.
Understanding the unique hemodynamics of constriction allows for the deduction of specific physical examination signs.
4
Select the physical examination findings that match these hemodynamics.
Identify Kussmaul sign (impaired right-sided accommodation of inspiratory venous return), prominent 'y' descent (rapid early right atrial emptying), and a pericardial knock (sudden halt of early ventricular filling).
These findings distinctly separate constrictive pericarditis from other causes of right heart failure and pericardial disease (like tamponade).

Key Concept

Physical examination differentiation of constrictive pericarditis from other cardiac and hepatic pathologies.
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Topics

Physical Examination Findings

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