A 43-year-old woman complains of fatigue and shortness of breath over the last 2 weeks. She has no chest pain, nausea, vomiting, or weight loss. She reports a recent upper respiratory tract infection. The patient does not use tobacco, alcohol, or illicit drugs. Her blood pressure is 98/55 mm Hg and pulse is 105/min. Jugular veins are distended with the patient in the seated position. Lungs are clear to auscultation. Chest x-ray is shown below. Which of the following is the most likely additional finding in this patient?

Question

A 43-year-old woman complains of fatigue and shortness of breath over the last 2 weeks.  She has no chest pain, nausea, vomiting, or weight loss.  She reports a recent upper respiratory tract infection.  The patient does not use tobacco, alcohol, or illicit drugs.  Her blood pressure is 98/55 mm Hg and pulse is 105/min.  Jugular veins are distended with the patient in the seated position.  Lungs are clear to auscultation.  Chest x-ray is shown below.  Which of the following is the most likely additional finding in this patient?

Quizplus · Accepted Answer

This patient's clinical presentation - recent upper respiratory tract infection, dyspnea, elevated jugular venous pressure (JVP), clear lung fields, and increased cardiac silhouette on chest x-ray - is suggestive of early cardiac tamponade due to a large pericardial effusion. Pericardial effusion is most commonly idiopathic (thought to be likely from a viral illness) but can also occur due to bacterial or fungal infections, neoplasms (metastatic or primary), post myocardial infarction, trauma, uremia, autoimmune diseases, and hypothyroidism. Large pericardial effusions typically appear on chest x-ray as an enlarged and globular cardiac silhouette with clear lung fields. Physical examination findings in pericardial effusion are nonspecific and vary depending on size of the effusion. However, the inability to palpate the point of maximal apical impulse is consistent with large pericardial effusion. Patients with cardiac tamponade may also have Beck's triad of hypotension, elevated JVP, and muffled heart sounds. cardiac silhouette (Choice A) Patients with viral myocarditis may present similarly with a history of recent upper respiratory infection, fatigue, dyspnea, elevated JVP, and cardiomegaly on imaging. However, patients typically have an audible S3 and bibasilar rales on physical examination, along with pulmonary vascular congestion on imaging studies. An abnormal S4 may be heard in patients with decreased left ventricular compliance, including those with hypertensive heart disease, aortic stenosis, or hypertrophic cardiomyopathy, and during the acute phase of myocardial infarction. (Choice B) Fixed splitting of the second heart sound is heard in patients with atrial septal defect. Chest x-ray may show an enlarged right atrium and ventricle along with prominent hilar or proximal pulmonary arterial vasculature. (Choice C) Intermittent ptosis can be seen in patients with myasthenia gravis, which can occur as an autoimmune disorder or as a paraneoplastic disorder in association with thymoma. These tumors present as anterior mediastinal (or retrosternal) masses on lateral chest x-ray projection. Cardiac size and silhouette are typically normal. (Choice E) An opening snap is heard in patients with mitral stenosis. Significant mitral stenosis leads to left atrial enlargement, which presents on chest x-ray as straightening of the left heart border, elevated left main bronchus, and pulmonary vascular congestion with cephalization of the blood flow to upper lobes. Lateral chest x-ray projection can reveal posterior displacement and impingement of the esophagus. (Choice F) Pulsus bisferiens (or biphasic pulse) refers to 2 strong systolic peaks of the aortic pulse from left ventricular ejection separated by a midsystolic dip. It can be palpated in patients with significant aortic regurgitation (with or without aortic stenosis), hypertrophic obstructive cardiomyopathy, and, occasionally, large patent ductus arteriosus. Educational objective: A pericardial effusion appears as an enlarged, globular cardiac silhouette on chest x-ray. Physical examination findings of effusion without cardiac tamponade include diminished heart sounds on auscultation and a maximal apical impulse that is difficult to palpate. References: Clinical clues to the causes of large pericardial effusions. (http://www.ncbi.nlm.nih.gov/pubmed/10967149) A systematic approach to evaluation of pericardial effusion and cardiac tamponade. (http://www.ncbi.nlm.nih.gov/pubmed/21808166)

A 43-Year-Old Woman Complains of Fatigue and Shortness of Breath