Name:
A 75-Year-Old with Hypotension
Description:
A 75-Year-Old with Hypotension
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T00H05M41S
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Upload Date:
2022-02-28T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
♪ (music) ♪
CATHY: Hi, welcome to Harrison's Podclass, where we discuss important concepts in internal medicine. I'm Cathy Handy. And I'm Charlie Wiener, and we're coming to you from the Johns Hopkins School of Medicine. ♪ (music) ♪ Welcome to Harrison's Podclass. This is Episode 9: A 75-Year-Old Woman with Hypotension. I'll read the question. A 75-year-old woman with widely metastatic non-small cell lung cancer presents with a systolic blood pressure of 73/52.
CATHY: She's complaining of fatigue and worsening dyspnea over the past three to five days. Her physical examination shows elevated neck veins. Chest radiograph shows a massive, water bottle-shaped heart shadow and no new pulmonary infiltrates. So, Cathy, what do you think of this case so far? I realize we're being given minimal information, but let's go with what we have.
CATHY: Well, what we have is that the patient is a 75-year-old woman, she has lung cancer, and she's presenting with sub-acute fatigue and dyspnea, and now, also with hypotension. The differential diagnosis is broad. She can have disease or treatment complications, especially she's at risk of pneumonia or pleural or pericardial effusions. She could be hypovolemic, and pulmonary embolism is certainly high on the differential and could explain both the symptoms and the vital signs.
CHARLIE: Okay, we hear that she has elevated neck veins. How does that help you narrow the differential?
CATHY: That tells me that she has elevated right-sided heart pressures. And I'm assuming she doesn't have any abnormal lung sounds because we didn't hear about that in question stem. But the imaging helps refine the differential further. The major finding there is that she has a massive water bottle-shaped heart, and this is the classic description of what the cardiac silhouette would like on chest x-ray in someone who has a large pericardial effusion. If she didn't have this, I'd probably put PE higher on the differential.
CATHY: But in thinking about pericardial effusions, it's most often caused by pericarditis or malignancy, and her metastatic lung cancer, I would put as her major risk factor. So in this case, I suspect she has a malignant pericadial effusion that's causing cardiac tamponade.
CHARLIE: Great. So, in that context, the question asks us, "Which of the following additional physical findings is most like present on her physical examination?" Option A is a fall in systolic blood pressure with inspiration that is greater than 10mm of mercury. Option B is lack of a fall of the jugular venous pressure with inspiration. Option C is a late diastolic murmur with an opening snap. Option D is pulsus parvus et tardus; and Option E is a rapid Y decent of the jugular venous pressure tracing.
CATHY: The classic findings in cardiac tamponade are typically referred to as "Beck's Triad." So, one, hypotension, which this patient has, and that's because of a decrease in ventricular filling and result in decrease in cardiac output. Two, is softer, absent heart sounds. We didn't hear about that in this case and isn't one of the choices but this happens because of the fluid that's physically between the heart and the chest wall where you would listen. And number three of the triad is jugular venous distention, which we did see in this patient.
CATHY: Other findings in cardiac tamponade, and you could do this at the bedside is to look for pulsus paradoxus. And this is when there's a greater than expected fall in systemic blood pressure during inspiration. The expected fall that you would see during inspiration is less than 10 millimeters of mercury. But in tamponade, because of the exaggerated intraventricular dependence, you get a greater fall in systemic blood pressure with inspiration, and it can be as high as 15 or more millimeters of mercury.
CATHY: So, the answer in this case is A - the fall in systolic blood pressure greater than 10 millimeters of mercury with inspiration. Another classic finding to know about in tamponade that's helpful if present is on EKG. You can see electrical alternans and that's when there's varying amplitude of the QRS complex beat to beat.
CHARLIE: Okay, so the other options that were listed in the question are not correct, where do you see those exam findings in other patients?
CATHY: Answer Choice B is the lack of a fall of jugular venous pressure with inspiration and that's known as Kussmaul's sign. That's usually seen in constrictive pericarditis or restrictive cardiomyopathy. And it happens because of a lack of compliance of the left ventricle. Option C, the late diastolic murmur with opening snap is the classic murmur that's heard in mitral stenosis. Option D, pulsus parvus et tardus - it's also known as a weaker small pulse that's late.
CATHY: And that's a late-stage exam finding in severe aortic stenosis. Finally, Option E, the rapid Y descent of jugular venous pressure tracing is the opposite of what happens in cardiac tamponade. In tamponade, you would get slower filling of the ventricle, which would show a slow or absent Y descent of the venous pressure tracing.
CHARLIE: Okay, while not mentioned in this question, let's briefly discuss how you'd manage this woman, Cathy.
CATHY: She's hypotensive, so needs urgent intervention, and she should be brought to a cardiac ICU for urgent echocardiogram to confirm the diagnosis. And then probably, also, pericardiocentesis, which would be used to remove fluid and normalize her hemodynamics. Once she's stabilized, there'd be more time to discuss a plan and a more deliberate therapeutic approach.
CHARLIE: Great, so the teaching point for this case is the characteristic physical findings of a patient with cardiac tamponade, in this case, likely due to a malignant pericardial effusion.
CATHY: And for more on this, you can see Harrison's chapter on cardiac tamponade, in the Disorders of the Heart chapter on the the pericardium. ♪ (music) ♪