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Difficulty: MediumPhysical Examination Findings

A 52-year-old woman is brought to the emergency department due to worsening shortness of breath, lightheadedness, and chest pain over the past 3 days. She reports having a viral upper respiratory infection two weeks ago. On examination, her blood pressure is 88/75 mm Hg, pulse is 118/min, and respirations are 24/min. Her extremities are cool and clammy. Which of the following physical examination findings are most likely to be present in this patient? (Select exactly 3 options)

  1. Decrease in systolic blood pressure of greater than 10 mm Hg during inspirationAnswer
  2. Muffled and distant heart soundsAnswer
  3. Jugular venous distention with an absent y descentAnswer
  4. D
    Bilateral basilar lung crackles
  5. E
    A third heart sound (S3) gallop

Answer

The correct physical examination findings are a decrease in systolic blood pressure of greater than 10 mm Hg during inspiration, muffled and distant heart sounds, and jugular venous distention with an absent y descent.
The patient's presentation is highly concerning for cardiac tamponade, an obstructive shock state that can develop as a complication of viral pericarditis. In cardiac tamponade, fluid accumulates in the pericardial space under high pressure, severely restricting ventricular filling. This pathophysiology leads to several classic physical examination findings. First, ventricular interdependence is exaggerated, causing pulsus paradoxus, which is defined as a decrease in systolic blood pressure of greater than 10 mm Hg during inspiration. Second, the insulating effect of the pericardial fluid results in muffled and distant heart sounds. Third, because the high intrapericardial pressure continuously impairs right ventricular filling throughout diastole, the y descent (representing rapid passive ventricular filling) on the jugular venous waveform is typically absent.

Step-by-Step Solution

1
Analyze the patient's clinical presentation and vital signs.
The patient exhibits hypotension, a narrow pulse pressure (88/75 mm Hg), tachycardia, and signs of poor perfusion following a recent viral illness, which strongly suggests obstructive shock.
Identifying the underlying shock mechanism is essential for predicting the expected physical examination findings.
2
Identify the most likely underlying diagnosis.
The combination of obstructive shock and a recent viral upper respiratory infection points to acute pericarditis complicated by cardiac tamponade.
Establishing the specific diagnosis allows for the correlation of classic physical signs associated with that pathophysiology.
3
Determine the expected physical examination findings for this condition.
Cardiac tamponade is characterized by pulsus paradoxus (inspiratory drop in systolic blood pressure), Beck's triad (including muffled heart sounds), and an absent y descent on the jugular venous waveform due to restricted diastolic filling.
These findings directly reflect the restrictive physiology of increased pericardial pressure.

Key Concept

Physical examination findings in cardiac tamponade include Beck's triad (hypotension, jugular venous distention, muffled heart sounds), pulsus paradoxus, and an absent y descent on the jugular venous pressure waveform.
Estimated Time:1m 30s
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Physical Examination Findings

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