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Difficulty: HardPhysical Examination Findings

During a routine follow-up in the outpatient cardiology clinic, a 48-year-old man complains of worsening abdominal fullness, leg swelling, and generalized fatigue over the last six months. The patient emigrated from India ten years ago and received a prolonged course of multiple antimicrobial agents for a chronic, productive cough when he was in his twenties. He reports no alcohol use. Vital signs include a temperature of 37.0°C (98.6°F), blood pressure of 112/74 mm Hg, and pulse of 94/min. Upon physical examination, the internal jugular veins remain distended while he is seated at a 45-degree angle; observation of the venous column reveals a paradoxical rise when the patient takes a deep breath. Palpation of the anterior chest wall yields an absent apical impulse. Cardiac auscultation reveals normal S1 and S2 sounds, immediately followed by a sharp, high-pitched early diastolic sound at the left sternal border. Lung fields are clear to auscultation bilaterally. Abdominal examination reveals a tense, protuberant contour with shifting dullness. The liver edge is easily palpable 4 cm below the right costal margin. Bilateral lower extremities exhibit 2+ pitting edema extending to the knees. Laboratory evaluation demonstrates a serum albumin of 3.2 g/dL, total bilirubin of 1.8 mg/dL, and aspartate aminotransferase of 62 U/L. Based on these physical examination findings, which of the following is the most likely diagnosis?

  1. A
    Restrictive cardiomyopathy
  2. B
    Cardiac tamponade
  3. Constrictive pericarditisAnswer
  4. D
    Cirrhosis of the liver
  5. E
    Cor pulmonale

Answer

The correct diagnosis is constrictive pericarditis, evidenced by signs of right heart failure combined with Kussmaul's sign and a classic pericardial knock.
The correct diagnosis is constrictive pericarditis. The physical examination findings are classic for this condition. The paradoxical rise in jugular venous pressure during inspiration is known as Kussmaul's sign, which indicates impaired right ventricular filling. The absent apical impulse is due to the thick, calcified pericardium encasing the heart. The sharp, early diastolic sound is a pericardial knock, occurring due to the sudden cessation of ventricular filling when the expanding ventricle hits the rigid pericardial sac. In a patient from an endemic region with a history of a treated chronic cough, prior pulmonary tuberculosis is the most likely underlying etiology for the chronic pericardial inflammation. The ascites, peripheral edema, and mild hepatic laboratory derangements are all secondary manifestations of congestive hepatopathy caused by the severe right-sided heart failure.

Step-by-Step Solution

1
Analyze the jugular venous pulse findings.
The JVP is elevated and exhibits a paradoxical rise on inspiration (Kussmaul's sign).
This finding localizes the pathology to impaired right ventricular filling, effectively ruling out primary hepatic disease as the sole cause of the patient's fluid overload.
2
Evaluate the cardiac palpation and auscultation findings.
The patient has an absent apical impulse and a sharp, high-pitched early diastolic sound (pericardial knock).
A pericardial knock is highly specific for the sudden cessation of ventricular filling caused by a thickened, rigid pericardium, distinguishing this condition from the S3 or S4 typically heard in restrictive cardiomyopathy.
3
Synthesize the physical findings with the patient's medical history and laboratory results.
The combination of right-sided heart failure signs, a pericardial knock, and Kussmaul's sign in a patient with a history of treated tuberculosis points directly to constrictive pericarditis.
Chronic inflammation from prior tuberculosis can lead to pericardial calcification. The resulting right-sided heart failure causes secondary congestive hepatopathy, explaining the ascites and mildly elevated liver enzymes.

Key Concept

Differentiating constrictive pericarditis from other causes of right heart failure using specific physical examination findings such as Kussmaul's sign and a pericardial knock.
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Topics

Physical Examination Findings

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