MDcooper
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26. 70-year-old woman presents with a cough, dyspnea, chest pain, and ankle swelling. She is ill appearing and cachectic. Her blood pressure is 100/70 mm Hg, with no inspiratory decrease, and her pulse is 100/min. She has absent rales on examination. She has jugular venous distention, with a decline during inspiration. Her apical cardiac impulse is decreased. She has an early third heart sound. Her liver is enlarged. An ECG reveals low QRS voltage. A chest x-ray film is clear. The cardiac silhouette is enlarged. Which of the following findings will most likely appear on an echocardiogram?
A. Collapsed right ventricle in diastole
B. Large right ventricle
C. Pericardial effusion
D. Thick myocardium
E. Thick pericardium
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| prathapdoctor
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C.pericardial effusion.
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| sarika
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its restrictive cardiomyopathy...i will go with D. Thick myocardium
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| robin082006
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D
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| Guptashutosh
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She has jugular venous distention, with a decline during inspiration. Her apical cardiac impulse is decreased. A chest x-ray film is clear. The cardiac silhouette is enlarged..
all highly suggestive of pericardial effusion and temponade...... option C
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| Aashi
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C. Pericardial effusion
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| MDcooper
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The correct answer is E. This patient has constrictive pericarditis. Filling is reduced abruptly when the elastic limit of the pericardium is reached. Such patients often appear to have a chronic illness. They have a positive Kussmaul's sign in which venous pressure declines in inspiration. The apical pulse is reduced. A pericardial knock is heard. QRS is low in voltage. The condition occurs because of the healing of a former acute pericarditis or a chronic pericardial effusion with obliteration of the pericardial cavity. Collapsed right ventricle in diastole (choice A) is seen in acute pericardial tamponade because of an obstruction to cardiac filling and concomitant elevated right-sided pressure. The accumulation of fluid in the pericardium is sufficient to cause a significant obstruction to inflow of blood to the ventricles. A large right ventricle (choice B) is seen typically in conditions such as a right ventricular infarct. The heart will appear large on a plain chest x-ray film. Management of a right ventricular infarct involves aggressive fluid resuscitation. A pericardial effusion (choice C) may result from accumulation of fluid in the pericardium. This may lead to cardiac tamponade. The effusion may be seen in patients with cancer or rheumatoid arthritis, or in those with conditions leading to bleeding into the pericardial space. A thick myocardium (choice D) is seen in restrictive cardiomyopathy. Abnormalities of the pericardium are not seen. This cardiomyopathy may result from amyloidosis, hemochromatosis, sarcoidosis, or scleroderma. It is characterized by the patient having a well-defined apical beat, left ventricular failure, S3, and bundle branch block.
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| prathapdoctor
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if it is constructive pericarditis,then why there is normal inspiratory decreas in JVP.
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| prathapdoctor
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normally there will be inspiratory decrease in JVP,abnormal raise of JVP during inspiration is called positive kussumauls sign, i think its given wrong in kaplan.
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| sarika
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a very confusing question...i looked up kaplan notes and this is what i found.
"Her blood pressure is 100/70 mm Hg, with no inspiratory decrease, " meaning no pulsus paradoxus...which would be present in cardiac tamponade & pericardial effusion.
"She has jugular venous distention, with a decline during inspiration." just like prathapdoctor said ,this is normal...kassmaul sign is increase in JVP with inspiration...which would be seen in constrictive pericarditis, restrictive cardiomyopathy.
The cardiac silhouette is enlarged" seen in pericardial effusion...acc to kaplan..heart size is normal in constrictive pericarditis/.
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| Guptashutosh
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i`ve never heard a term like thick pericardium , whatever be the source i do no agree with md cooper explanation, its all above my head(i`m a poor guy with iq of just 122, i may not be that good ) ...... after reading the Q what comes in my mind is pericardial effusin and nothing else ..... i`ll stick to it
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| prathapdoctor
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hey,that might be the explanation given in kaplan,i think kaplan is wrong there,so i think it would be better to stick to pericardial effusion only .
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| Aashi
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Well I stand with the explanation that MD cooper submitted..I did get that wrong ,but giving the q a second thought, there are several points which DID point towards constrictive pericarditis( CP).. kausmauls sign is NOT SPECIFIC for C.P ..In C.P, the PA xray can be normal,but lateral view will show the calcified pericardium and if there is pericardial effusion along with it, the silhoutte will be increased, EKG did show low voltage QRS,and if it was PERiCARDIAL effusion/cardiac tamponade,one shld think of ELECTRICAL alterans along with low voltage QRS,which is produced by the movement of the heart within the effusion, thirdly and EARLY S3 which is heard in this pt is called the PERICARDIAL KNOCK ,which corresponds with the sudden cessation of ventricular filling early in diastole and which is heard in constrictive pericarditis rather than in an effusion,and a pericarditis-effusion causes a 'PERICARDIAL RUB' to be precise..and together with the other supporting signs like inc JVP,impalpable APEX,dyspnea--->constrictive pericarditis is NOT completely out of the picture..
GL
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| MDcooper
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this is a kaplan explaination.It contradicts all the little knowledge that I have.I mean if we started to think about evrything this critically then there is just no logic in any answer that we give.I go with effusion too on exam.I personally think kaplan is wrong on this one.and again looking for the obvious,it says pericardial effusion lead to this pericardial thickening.so how can u rule out effusion al together.
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| young_doc
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This is a weird question...seems to be a mix of both Constrictve Pericardial and Pericardial Effusions??!!!!! http://www.emedicine.com/MED/topic1786.htm, http://www.emedicine.com/med/topic1782.htm
Constrictive Pericarditis:
-Elevated jugular venous pressures are an almost universal finding.
-Sinus tachycardia is common while the blood pressure is normal or low, depending on the stage of the disease process.
-The apical impulse is often impalpable, and the patient may have distant or muffled heart sounds.
-A pericardial knock, which corresponds with the sudden cessation of ventricular filling early in diastole, occurs in approximately half the cases and may be mistaken for an S3 gallop. However, a knock is of higher frequency than an S3 and occurs slightly earlier in diastole.
-Pulsus paradoxicum (paradoxus) is a variable finding and, if present, rarely exceeds 10 mm Hg unless a concomitant pericardial effusion with an abnormally elevated pressure exists.
-The Kussmaul sign (ie, elevation of systemic venous pressures with inspiration) is a common nonspecific finding, but this sign is also observed in patients with right ventricular failure, restrictive cardiomyopathy, right ventricular infarction, and tricuspid stenosis, although, importantly, not in patients with cardiac tamponade.
-Hepatomegaly
Pericardial Effusions:
-Classic Beck triad of pericardial tamponade (hypotension, muffled heart sounds, jugular venous distension)
-Pulsus paradoxus: Exaggeration of physiologic respiratory variation in systemic blood pressure, defined as a decrease in systolic blood pressure of more than 10 mm Hg with inspiration, signaling falling cardiac output during inspiration.
-Pericardial friction rub: The most important physical sign of acute pericarditis may have up to 3 components per cardiac cycle and is high-pitched, scratching, and grating. It can sometimes be elicited only when firm pressure with the diaphragm of the stethoscope is applied to the chest wall at the left lower sternal border. The pericardial friction rub is heard most frequently during expiration with the patient upright and leaning forward.
-Widened pulse pressure
-Tachycardia
-Hepatojugular reflux: This can be observed by applying pressure to the periumbilical region. A rise in the jugular venous pressure (JVP) of greater than 3 cm H2O for more than 30 seconds suggests elevated central venous pressure. Transient elevation in JVP may be normal.
-Findings include enlarged cardiac silhouette
-Hepatomegaly
I would put my money on Constrictive Pericarditis if i HAD to choose....
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