59
Foreword
Information about a real patient is presented in stages (boldface type) to expert clinicians (Drs Yee and Dudzinski), who respond to the information, sharing reasoning with the reader (regular type). A discussion by the authors follows.A 34-year-old man with a 2-year history of unexplained steroid-refractory polyneuropathy, lower-extremity edema, and monoclonal gammopathy presented to our tertiary care center with 3 days of rapidly progressive dyspnea. The patient's vital signs were notable for a temperature of 37.0ºC, heart rate of 122 bpm, blood pressure of 80/60 mm Hg, respiratory rate of 22 breaths per minute, and oxygen saturation of 94% on 2 L supplemental oxygen. Physical examination revealed a cachectic young man in mild respiratory distress with a jugular venous pressure of 12 cm H 2 O and a positive Kussmaul sign, pulsus paradoxus of 6 mm Hg, regular tachycardic rhythm without murmur or gallop, but a prominent P2 sound with heave at the left sternal border, bilateral fine crackles, and decreased bibasilar breath sounds. Abdominal examination revealed mild hepatomegaly. Peripheral examination was notable for warm and well-perfused lower extremities with 2+ pitting edema extending to the sacrum but without evidence of venous stasis dermopathy, leg tenderness, erythema, warmth, or palpable cord. There was also mild, diffuse skin hyperpigmentation.Dr Dudzinski: On this acute presentation with new dyspnea and hypotension, the onus is on the cardiologist to rapidly evaluate and exclude possible diagnoses such as pulmonary embolism (PE), myocardial infarction, pericardial tamponade, and decompensated heart failure. Jugular venous distention can be consistent with all of these diagnoses, but it importantly excludes other shock phenotypes such as distributive (eg, septic) or hemorrhagic shock. Pitting pedal and sacral edema may also be consistent with elevated central venous pressures; the lack of stasis dermopathy may argue for a relatively new overload syndrome, for example, heart failure or constrictive pericarditis. Bilateral crackles and decreased bibasilar breath sounds could indicate pulmonary edema and pleural effusions. Despite tachycardia and hypotension with jugular venous distention, a pulsus paradoxus of 6 mm Hg argues against tamponade physiology; moreover, cardiac sounds were not obscured. The finding of a Kussmaul signfailure of the jugular venous pressure level to decrease with inspiration-may be seen in a number of conditions, including constrictive pericarditis and restrictive cardiomyopathy, acute PE, acute right ventricular (RV) infarction, severe tricuspid valvulopathy, right-sided cardiac tumors, and acute sequelae of cor pulmonale that may result from primary pulmonary hypertension or congenital heart disease. The parasternal heave suggests RV dilatation; the augmented P2, elevated pulmonary pressures. Accordingly, acute PE is a possibility that must be considered, as well as acute-on-chronic right heart insults from congenital, shunt, or valvular lesions. Because the acuity ...
