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Zorluk: OrtaPhysical Examination Findings

A 52-year-old man presents to the clinic with a 3-month history of progressively worsening shortness of breath, abdominal swelling, and lower extremity edema. Fifteen years ago, he was treated with mantle field radiation therapy for Hodgkin lymphoma. His temperature is 37.0°C (98.6°F), blood pressure is 112/76 mmHg, pulse is 98/min, and respiratory rate is 18/min. Physical examination reveals marked jugular venous distention. Upon deep inspiration, the jugular veins become further distended. Lung fields are clear to auscultation bilaterally. Abdominal examination demonstrates shifting dullness and a liver edge palpable 4 cm below the right costal margin. Bilateral 2+ pitting edema is noted up to the knees. Which of the following additional physical examination findings is most likely to be present in this patient?

  1. A high-frequency early diastolic sound heard just after the second heart soundCevap
  2. B
    An inspiratory decrease in systolic blood pressure of greater than 10 mmHg
  3. C
    A blowing, holosystolic murmur at the lower left sternal border that increases with inspiration
  4. D
    A sustained, outward systolic thrust palpable over the left parasternal area
  5. E
    A low-frequency, late diastolic sound heard just prior to the first heart sound

Cevap

A high-frequency early diastolic sound heard just after the second heart sound
This patient's presentation of progressive right-sided heart failure (hepatomegaly, ascites, peripheral edema) with clear lungs, combined with a history of mantle field radiation therapy, strongly suggests constrictive pericarditis. The physical examination finding of jugular venous distention that paradoxically increases during inspiration describes Kussmaul sign. This is a hallmark of impaired right-sided diastolic filling because the right ventricle cannot accommodate the increased venous return during inspiration. In constrictive pericarditis, the thickened, scarred, and rigid pericardium allows rapid early ventricular filling, which is then abruptly halted by the unyielding pericardial sac. This sudden deceleration of blood produces a characteristic high-frequency, early diastolic sound known as a pericardial knock, which occurs slightly earlier in diastole than a typical S3 gallop.

Adım Adım Çözüm

1
Analyze the patient's presenting symptoms and history.
The patient has isolated right-sided heart failure (ascites, lower extremity edema, hepatomegaly) and a significant risk factor: a history of mantle field radiation therapy.
Identifying the primary clinical syndrome and risk factors is essential to narrow the differential diagnosis for heart failure.
2
Interpret the specific physical examination findings.
The physical exam shows a positive Kussmaul sign (jugular veins becoming further distended on deep inspiration) and clear lungs.
Kussmaul sign indicates severely impaired right-sided diastolic filling, pointing away from left-sided heart failure and towards constrictive pericarditis or restrictive cardiomyopathy.
3
Synthesize the findings to establish the most likely diagnosis.
The combination of late-onset right heart failure, Kussmaul sign, and a history of radiation strongly establishes a diagnosis of constrictive pericarditis.
Mantle field radiation therapy is a classic cause of progressive pericardial scarring, leading to constrictive pericarditis years or decades later.
4
Determine the corresponding cardiac auscultation finding.
Constrictive pericarditis is classically associated with a pericardial knock, which is a high-frequency, early diastolic sound.
The rigid pericardium abruptly halts ventricular filling in early diastole, producing the characteristic 'knock'.

Anahtar Kavram

Constrictive pericarditis commonly presents with right-sided heart failure, a positive Kussmaul sign, and a characteristic early diastolic pericardial knock. Radiation therapy is a major risk factor.
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Physical Examination Findings

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