Which of the following additional findings would you expect to observe in this patient?

A 30-year-old Caucasian female with a history of rheumatoid arthritis presents to your clinic with pleuritic chest pain that improves while leaning forward. Which of the following additional findings would you expect to observe in this patient?

1.Increase in jugular venous pressure on inspiration
2.Exaggerated amplitude of pulse on inspiration
3.Pulsatile abdominal mass
4.Continous machine like murmur
5.S3 heart sound

sol:

The patient described in the question stem has pericarditis, a common complication of rheumatoid arthritis. Pericarditis can restrict venous return to the right heart resulting in an increase in JVP on inspiration (Kussmaul’s sign).
Pericarditis is inflammation of the pericardial sac. There are 4 types of pericarditis (serous, fibrinous, hemorrhagic, and constrictive) and each is associated with particular diseases (detailed in the topic “Pericarditis”). On inspiration, more blood returns to the heart as intrathoracic pressure becomes more negative. However, pericarditis impedes filling of the right ventricle, and blood is not as effectively removed from the jugular vein, increasing the pressure within it. This phenomenon can be observed at the bedside and is known as Kussmaul’s sign. Kussmaul’s sign is also observed in cardiac tamponade and restrictive cardiomyopathy.
Goyle et al. review the etiologies and diagnosis of pericarditis. They report that pericarditis is most often caused by viral infection, though it can be bacterial or fungal in rare cases. Non-infectious causes include autoimmune disease (as in this case), renal failure, injury to the mediastinal area, and certain drugs (notably hydralazine and procainamide).
Kass et al. review the differential diagnosis of pleuritic chest pain, which range from life-threatening to benign, self-limited conditions. Pulmonary embolism is the most common potentially life-threatening cause of pleuritic chest pain but other clinically significant conditions include pericarditis, pneumonia, myocardial infarction, and pneumothorax.
Illustration A shows an example of fibrinous pericarditis.