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Difficulty: HardPhysical Examination Findings

A 52-year-old man comes to the clinic for progressive abdominal swelling, generalized fatigue, and bilateral lower extremity edema over the past 4 months. His medical history is significant for Hodgkin lymphoma, which was treated with chemotherapy and mantle field radiation 25 years ago. His pulse is 95/min, and blood pressure is 110/70 mm Hg. Physical examination reveals jugular venous distention that becomes paradoxically more pronounced upon deep inspiration. Abdominal examination shows shifting dullness and a palpable, non-pulsatile liver edge 4 cm below the right costal margin. Bilateral 2+ pitting edema is present up to the knees. Which of the following additional cardiovascular physical examination findings is most likely to be present in this patient?

  1. A sharp, high-pitched early diastolic sound occurring shortly after the second heart soundAnswer
  2. B
    An inspiratory decrease in systolic arterial pressure of greater than 10 mm Hg
  3. C
    A harsh, holosystolic murmur at the left lower sternal border that increases with inspiration
  4. D
    A low-pitched, mid-diastolic rumbling murmur with a preceding opening snap
  5. E
    A palpable systolic thrill over the right second intercostal space with a delayed carotid upstroke

Answer

A sharp, high-pitched early diastolic sound occurring shortly after the second heart sound
The correct answer is a sharp, high-pitched early diastolic sound occurring shortly after the second heart sound. This patient's presentation of progressive right-sided heart failure (edema, hepatomegaly, ascites) and a history of mantle field radiation points strongly to constrictive pericarditis. The physical examination confirms this with the presence of Kussmaul sign (a paradoxical rise in jugular venous pressure during inspiration). In constrictive pericarditis, the fibrotic, rigid pericardium restricts ventricular expansion. When the ventricles fill rapidly in early diastole, they abruptly hit the physical limit of the thickened pericardium, creating a sharp, high-pitched early diastolic sound known as a pericardial knock.

Step-by-Step Solution

1
Analyze the patient's history and presenting symptoms.
The patient has a history of mediastinal (mantle field) radiation and presents with signs of severe right-sided heart failure (peripheral edema, hepatomegaly, ascites).
Prior radiation therapy is a major risk factor for delayed cardiac complications, most notably constrictive pericarditis, restrictive cardiomyopathy, and valvular disease.
2
Evaluate the specific physical examination findings provided in the stem.
The patient exhibits a paradoxical rise in jugular venous pressure during inspiration, known as Kussmaul sign.
Normally, JVP falls during inspiration due to decreased intrathoracic pressure. Kussmaul sign indicates impaired right ventricular filling, highly specific for constrictive pericarditis or restrictive cardiomyopathy.
3
Correlate the suspected diagnosis with expected auscultatory findings.
Constrictive pericarditis is classically associated with a pericardial knock.
A pericardial knock is a high-pitched, early diastolic sound caused by the sudden cessation of rapid ventricular filling due to a rigid, thickened pericardium. It occurs slightly earlier in diastole than an S3 gallop.

Key Concept

Patients with prior mediastinal radiation presenting with right heart failure and Kussmaul sign likely have constrictive pericarditis, classically associated with an early diastolic pericardial knock.
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Topics

Physical Examination Findings

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