WBR0021

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Author Aarti Narayan MBBS, Raviteja Reddy Guddeti MBBS
Exam Type USMLE Step 2 CK
Main Category Internal medicine
Sub Category Oncology
Prompt A 50-year-old man presents to the clinic with complaints of fatigue, shortness of breath on exertion and weight gain . He reports difficulty sleeping for the past 3 weeks because his shortness of breath worsens when he lies down. His past medical history is significant for non-Hodgkin lymphoma treated with chemoradiotherapy 6 years ago. His blood pressure is 110/60 mmHg, heart rate is 110/min, and temperature is 36.7 ᵒC (98 ᵒF). Physical examination is remarkable for abdominal swelling and lower extremity edema. Heart sounds are muffled and jugular venous pressure (JVP) is 6 cm above the sternal angle. Abdominal examination reveals hepatomegaly and minimal ascites. EKG shows low voltage QRS complexes and flattened T waves. What is the most likely diagnosis?
Answer A Constrictive pericarditis
Answer A Explanation Constrictive pericarditis is caused by calcification and fibrosis of the pericardium, which prevents the filling of the right heart. Signs of right heart failure include: JVD, Kussmal sign, a knock heard in diastole, ascites, edema and hepato-splenomegaly. A CXR shows calcification of the pericardium. The best initial test is a CXR. CT and MRI are more accurate. Echocardiogram is used to exclude other causes of right heart failure, the myocardium moves normally in constrictive pericarditis. It is treated with diuretics and surgery.
Answer B Acute pericarditis
Answer B Explanation [[AnswerBExp::Acute pericarditis is associated with severe retrosternal chest pain aggravated with supine position and inspiration and alleviated when sitting. The history of increased abdominal girth, edema and hepatomegaly are findings of chronic pericarditis, rather than acute.]]
Answer C Cardiac tamponade
Answer C Explanation [[AnswerCExp::Cardiac tamponade is a life threatening condition, which presents with distant heart sounds, hypotension and jugular veins distention, a triad called Beck's triad. It is caused by the presence of fluid in the virtual pericardial space, which compresses the heart chambers causing hypotension due to cardiogenic shock. Cold clammy skin, cyanotic extremities and decreased urine output can be noted. The history of increased abdominal girth, edema, and hepatomegaly are not characteristic findings of cardiac tamponade.]]
Answer D Cor pulmonale
Answer D Explanation [[AnswerDExp::The absence of history of a chronic pulmonary disease makes cor pulmonale a less likely diagnosis. Right heart failure is also used interchangeably with cor pulmonale when the pathology is caused by an underlying lung disease, such as emphysema or chronic bronchitis.]]
Answer E Hypertrophic cardiomyopathy
Answer E Explanation [[AnswerEExp::Hypertrophic cardiomyopathy generally presents with dyspnea, palpitations, chest pain and fatigue. Hypertrophic cardiomyopathy can cause sudden cardiac death in young adolescents and adults due to cardiac arrhytmias. A past history of irradiation, distant heart sounds on auscultation, and prominent x and y descent on JVP are more consistent with the diagnosis of constrictive pericarditis.]]
Right Answer A
Explanation [[Explanation::The correct answer is constrictive pericarditis. The history of radiation for lymphoma treatment, likely caused pericardial scarring. Signs of right heart failure (hepatomegaly, ascitis, lower extremity edema) along with characteristic JVP findings suggest chronic constrictive pericarditis.

Educational Objective: Constrictive pericarditis can be caused by radiation therapy to the chest in a patient with lymphoma. It typically presents with distant heart sounds and fatigue and signs and symptoms of chronic right heart failure, such as: jugular veins distention, hepatomegaly, ascites and lower extremity edema.
References: Master the Boards for Step 2CK, 2013 edition, page 101]]

Approved Yes
Keyword Constrictive pericarditis, Pericarditis, Pericardium, right heart failure
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