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{{WBRQuestion
{{WBRQuestion
|QuestionAuthor=Aarti Narayan MBBS, Raviteja Reddy Guddeti MBBS
|QuestionAuthor=Aarti Narayan MBBS, Raviteja Reddy Guddeti MBBS (Reviewed by Gonzalo Romero)
|ExamType=USMLE Step 2 CK
|ExamType=USMLE Step 2 CK
|MainCategory=Internal medicine
|MainCategory=Internal medicine
Line 20: Line 20:
|MainCategory=Internal medicine
|MainCategory=Internal medicine
|SubCategory=Oncology, Cardiovascular, Oncology
|SubCategory=Oncology, Cardiovascular, Oncology
|Prompt=A 50 yr old male presents to the clinic with history of fatigue, weakness, weight gain, increased abdominal girth, and swelling. History of present illness reveals orthopnea and paroxysmal nocturnal dyspnea. Past history is significant for having undergone radiotherapy for lymphoma. Blood pressure is found to be 100/60 mm Hg, respiratory rate of 15/min and HR 100 beats/min. JVP shows a prominent x and y descent. Abdominal examination shows hepatomegaly and ascites. Auscultation demonstrates distant heart sounds and EKG shows low voltage QRS complexes and fattened T wave. What is the most likely diagnosis?
|Prompt=A 50-year-old male presents to the clinic due to fatigue, weakness and weight gain.  Upon interrogration, he  has orthopnea, paroxysmal nocturnal dyspnea, abdominal swelling and lower extremity edema. His past medical history is significant for lymphoma treatment with radiotherapy. On physical examination, his vitals are:  BP 100/60 mmHg, RR 15/min and HR 100bpm. He has distant heart sounds and a prominent x and y descent on jugular examination. Abdominal examination shows hepatomegaly and ascites. EKG shows low voltage QRS complexes and flattened T waves. What is the most likely diagnosis?
|Explanation=The correct answer is constrictive pericarditis. The patients past history of irradiation for lymphoma likely caused scarring of the pericardium. Signs of right heart failure along with characteristic JVP findings suggest chronic constrictive pericarditis.
|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.
|AnswerA=Constrictive pericarditis
|AnswerA=Constrictive pericarditis
|AnswerAExp=Constrictive pericarditis is the correct answer.
|AnswerAExp=Constrictive pericarditis  
|AnswerB=Acute pericarditis
|AnswerB=Acute pericarditis
|AnswerBExp=Acute pericarditis is associated with severe retrosternal chest pain. History of increased abdominal girth, edema and hepatomegaly are not findings one would expect with the diagnosis of acute pericarditis.
|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.
|AnswerC=Cardiac tamponade
|AnswerC=Cardiac tamponade
|AnswerCExp=Cardiac tamponade is a life threatening condition where in the pericardial fluid surrounding the heart compresses the heart causing cardiogenic shock and hypotension. 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.
|AnswerCExp=[[Cardiac tamponade]] is a life threatening condition, which presents with distant heart sounds, hypotension and jugular veins distention. It is caused by the presence of  fluid in the virtual pericardial space, which compresses the heart causing cardiogenic shock and hypotension. 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.
|AnswerD=Cor pulmonale
|AnswerD=Cor pulmonale
|AnswerDExp=Absence of history of a chronic pulmonary disease makes cor pulmonale a less likely diagnosis.
|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.
|AnswerE=Hypertrophic cardiomyopathy
|AnswerE=Hypertrophic cardiomyopathy
|AnswerEExp=Hypertrophic cardiomyopathy generally presents with dyspnea, palpitations, chest pain and fatigue. Hypertrophic cardiomyopathy can cause sudden cardiac death. 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.
|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.
|RightAnswer=A
|RightAnswer=A
|Approved=Yes
|Approved=Yes
}}
}}
{{WBRImage}}
{{WBRImage}}

Revision as of 20:16, 15 March 2014

 
Author PageAuthor::Aarti Narayan MBBS, Raviteja Reddy Guddeti MBBS (Reviewed by Gonzalo Romero)
Exam Type ExamType::USMLE Step 2 CK
Main Category MainCategory::Internal medicine
Sub Category SubCategory::Oncology, SubCategory::Cardiovascular, SubCategory::Oncology
Prompt [[Prompt::A 50-year-old male presents to the clinic due to fatigue, weakness and weight gain. Upon interrogration, he has orthopnea, paroxysmal nocturnal dyspnea, abdominal swelling and lower extremity edema. His past medical history is significant for lymphoma treatment with radiotherapy. On physical examination, his vitals are: BP 100/60 mmHg, RR 15/min and HR 100bpm. He has distant heart sounds and a prominent x and y descent on jugular examination. Abdominal examination shows hepatomegaly and ascites. EKG shows low voltage QRS complexes and flattened T waves. What is the most likely diagnosis?]]
Answer A AnswerA::Constrictive pericarditis
Answer A Explanation AnswerAExp::Constrictive pericarditis
Answer B AnswerB::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 AnswerC::Cardiac tamponade
Answer C Explanation [[AnswerCExp::Cardiac tamponade is a life threatening condition, which presents with distant heart sounds, hypotension and jugular veins distention. It is caused by the presence of fluid in the virtual pericardial space, which compresses the heart causing cardiogenic shock and hypotension. 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 AnswerD::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 AnswerE::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 RightAnswer::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:
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Approved Approved::Yes
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Image [[WBRImage::|]] Caption WBRImageCaption::no-display Position [[WBRImagePlace::|]]