A 65-year-old man comes to the physician for fatigue, poor appetite, and lower-leg swelling. Past medical history is significant for hypertension, type 2 diabetes mellitus, chronic cough, chest infections, and lower-extremity peripheral artery disease. The patient has a 40-pack-year smoking history. He does not use alcohol or illicit drugs. Physical examination shows a barrel-shaped chest, with bilateral scattered wheezing on auscultation. The patient's abdomen is distended, and the liver edge is palpated 4 cm below the right costal margin. There is 2+ pitting edema and dilated, tortuous superficial veins over both lower extremities. Manual pressure on the abdomen causes persistent distension of the jugular veins. His serum sodium level is 135 mEq/L, and creatinine is 1.2 mg/dL. An abnormality of which of the following is most likely the cause of this patient's edema?

Question

A 65-year-old man comes to the physician for fatigue, poor appetite, and lower-leg swelling.  Past medical history is significant for hypertension, type 2 diabetes mellitus, chronic cough, chest infections, and lower-extremity peripheral artery disease.  The patient has a 40-pack-year smoking history.  He does not use alcohol or illicit drugs.  Physical examination shows a barrel-shaped chest, with bilateral scattered wheezing on auscultation.  The patient's abdomen is distended, and the liver edge is palpated 4 cm below the right costal margin.  There is 2+ pitting edema and dilated, tortuous superficial veins over both lower extremities.  Manual pressure on the abdomen causes persistent distension of the jugular veins.  His serum sodium level is 135 mEq/L, and creatinine is 1.2 mg/dL.  An abnormality of which of the following is most likely the cause of this patient's edema?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d343_4298_bc81_1de5a3235ed2_MD0003_00 11ec25c8_d343_4299_bc81_1d1b4e1a0e01_MD0003_00 This patient's clinical findings-long-term tobacco use, chronic cough, barrel-shaped chest, elevated jugular venous pressure, and enlarged liver-are consistent with chronic obstructive pulmonary disease (COPD) with cor pulmonale. Cor pulmonale refers to impaired function of the right ventricle caused by pulmonary hypertension that occurs due to underlying diseases of the lungs (COPD, interstitial lung disease), pulmonary vasculature (idiopathic pulmonary arterial hypertension), or obstructive sleep apnea. By convention, right ventricular dysfunction due to left heart disease or congenital heart disease is not considered cor pulmonale. Patients with cor pulmonale typically present with exertional symptoms (eg, dyspnea, angina, syncope), anorexia or abdominal pain (due to hepatic congestion), and peripheral edema. Physical examination may show a loud P2 (pulmonic component of 2nd heart sound) and a right ventricular 3rd heart sound, tricuspid regurgitation murmur (holosystolic at the left lower sternal border, augments with inspiration), elevated jugular venous pressure with hepatojugular reflux, hepatomegaly with pulsatile liver, and occasionally ascites or pleural effusion. The diagnosis of cor pulmonale is based primarily on clinical features and echocardiographic findings (eg, right ventricular hypertrophy, tricuspid regurgitation with right atrial enlargement). If necessary, definitive diagnosis can be made using right heart catheterization showing elevated pulmonary artery systolic pressure (>25 mm Hg). (Choice A) Increased portal venous resistance (portal hypertension) is seen in the setting of hepatic cirrhosis or extrahepatic portal vein thrombosis. Chronic liver disease is associated with stigmata such as palmar erythema, spider angiomata, caput medusae, and gynecomastia. Complications of cirrhosis with portal hypertension include ascites, spontaneous bacterial peritonitis, and variceal bleeding. (Choice C) The pulmonary capillary wedge pressure (PCWP) is an estimation of left ventricular end-diastolic pressure, and is elevated in patients with left ventricular systolic and/or diastolic dysfunction. Patients with elevated PCWP typically have signs of pulmonary edema on lung auscultation. (Choices D and E) Hypoalbuminemia may occur due to decreased hepatic synthesis (cirrhosis) or increased urinary or gastrointestinal protein loss (ie, nephrotic syndrome, protein-losing enteropathy). Nephrotic syndrome typically presents with periorbital and pedal edema that may progress to generalized edema (anasarca), ascites, and pleural effusions. Patients can also develop severe intravascular hypovolemia due to over-diuresis and fluid movement into the interstitial spaces. This patient does not have anasarca or facial edema; he also does not have stigmata of chronic liver disease or diarrhea (to suggest enteropathy). Educational objective: Cor pulmonale is impaired function of the right ventricle due to pulmonary hypertension that usually occurs due to chronic lung disease. Signs of right ventricular failure include: Elevated jugular venous pressure Right ventricular 3rd heart sound Tricuspid regurgitation murmur Hepatomegaly with pulsatile liver Lower-extremity edema, ascites, and/or pleural effusions Echocardiogram will show signs of increased right heart pressures, and right heart catheterization will show pulmonary systolic pressure >25 mm Hg. References: Pulmonary hypertension in chronic lung diseases. (http://www.ncbi.nlm.nih.gov/pubmed/24355635)

A 65-Year-Old Man Comes to the Physician for Fatigue, Poor