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Difficulty: Very hardPhysical Examination Findings

A 61-year-old woman presents to the outpatient internal medicine clinic for the evaluation of progressive fatigue, lower extremity edema, and exertional dyspnea that have worsened over the last four months. During the clinical interview, the physician observes a sudden onset of violaceous flushing over her face and upper chest that resolves spontaneously after 10 minutes. The patient mentions a one-year history of episodic, explosive watery diarrhea and intermittent wheezing. On physical examination, her lungs are clear to auscultation bilaterally. Abdominal examination reveals a tender, enlarged liver with a distinct systolic pulsation. Which of the following physical examination findings are characteristically present in this patient's underlying cardiovascular condition? (Select all that apply)

  1. A holosystolic murmur at the left lower sternal border that augments in intensity during inspirationAnswer
  2. A prominent systolic wave in the jugular venous pulse that obscures the x descentAnswer
  3. C
    An early diastolic, high-pitched decrescendo murmur best heard at the left third intercostal space
  4. D
    A low-pitched, mid-diastolic rumbling murmur at the cardiac apex that is accentuated in the left lateral decubitus position
  5. E
    Bilateral, fine end-inspiratory crackles localized to the posterior lung bases

Answer

The correct findings are a holosystolic murmur at the left lower sternal border that augments during inspiration and a prominent systolic wave in the jugular venous pulse that obscures the x descent.
The correct answers describe the classic physical examination findings of tricuspid regurgitation: a holosystolic murmur at the left lower sternal border that increases with inspiration (Carvallo sign) and a prominent 'c-v' (regurgitant) wave in the jugular venous pulse. This patient's classic triad of flushing, diarrhea, and wheezing, combined with right heart failure and a pulsatile liver, points to carcinoid syndrome with carcinoid heart disease. This condition causes plaque-like fibrotic deposits on the endocardium of the right heart, leading to tricuspid valve retraction and regurgitation.

Step-by-Step Solution

1
Analyze the patient's systemic symptoms to formulate an underlying diagnosis.
The combination of episodic flushing, watery diarrhea, and wheezing is highly characteristic of carcinoid syndrome.
These symptoms are caused by the systemic release of vasoactive substances like serotonin, histamine, and tachykinins from a neuroendocrine tumor (typically metastatic to the liver).
2
Correlate the systemic disease with the cardiovascular presentation.
The patient has signs of right-sided heart failure (edema, hepatomegaly) and a pulsatile liver, indicating carcinoid heart disease resulting in tricuspid regurgitation.
Carcinoid plaques form predominantly on the right-sided heart valves, leading to tricuspid regurgitation and/or pulmonic stenosis. The pulsatile liver is a hallmark of severe tricuspid regurgitation.
3
Identify the specific physical examination findings associated with tricuspid regurgitation.
Tricuspid regurgitation produces a holosystolic murmur that increases with inspiration (Carvallo sign) and a prominent systolic (c-v) wave in the jugular venous pulse.
Inspiration increases venous return to the right heart, amplifying right-sided murmurs. The incompetent tricuspid valve allows systolic backflow into the vena cava, producing the abnormal jugular venous pulse wave.

Key Concept

Carcinoid heart disease predominantly causes right-sided valvular lesions (tricuspid regurgitation and pulmonic stenosis) because vasoactive amines are inactivated in the lungs, typically sparing the left heart.
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Physical Examination Findings

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