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Presentation
Case Findings: A 45-year-old female who immigrated to the United states 10 years ago from South America presents with a 4-month history of dyspnea on exertion. She denies any chest pain, but notes significant fluid accumulation in her abdomen and lower extremities. She has a history of childhood tuberculosis that was treated. Her ECG is unremarkable. Her chest X-ray is shown below.
In addition to an elevated jugular venous pressure and a 3rd heart sound, which of the following is likely to be found on physical exam?
101% Rapid y descent on JVP exam
109% Double systolic apical impulse on palpation
106% Loud, fixed split P2 on ascultation
93% Cannon a wave in JVP exam
Correct Answer:
A. Rapid y descent on JVP exam. The patient presents with signs and symptoms of congestive heart failure. Her history of tuberculosis puts her at risk for constrictive pericarditis, and the chest X-ray shows the classic calcifications of the disorder. In constrictive pericarditis, the physical exam may show a rapid y descent in the JVP that represents early and rapid filling of the right ventricle in diastole. Other findings would be a rapid x descent, a pericardial knock that is similar to a 3rd heart sound, ascites, edema, and Kussmaulβs sign. A double systolic impulse can be seen in hypertrophic cardiomyopathy. A loud and fixed split P2 suggests pulmonary HTN. Cannon a waves are seen in AV dissociation. Opening snaps are usually brief, high pitched diastolic sounds caused by mitral stenosis.