PANCE Blueprint Pulmonary (12%)

Cor pulmonale

Patient will present as → a 65-year-old man who presents with a chronic productive cough, dyspnea, and wheezing. Examination reveals cyanosis, distended neck veins, and a prominent epigastric pulsation

Cor pulmonale is right ventricular enlargement and eventually failure secondary to a lung disorder that causes pulmonary artery hypertension. 

  • Lung disorders such as PE, vasculitis, ARDS, COPD (most common), Asthma, and ILD causes pulmonary artery hypertension.
  • Pulmonary artery hypertension then leads to right ventricular failure
  • Findings include peripheral edema, neck vein distention, hepatomegaly, and a parasternal lift

Diagnosis usually requires echocardiography or radionuclide imaging and sometimes right heart catheterization

Diagnose and treat the underlying disorder

  • Early identification and treatment of the cause are important before cardiac structural changes become irreversible
  • Although patients may have significant peripheral edema, diuretics are not helpful and may be harmful; small decreases in preload often worsen cor pulmonale
Cor Pulmonale

Cor Pulmonale

Question 1
A 65-year-old man presents with a chronic productive cough, dyspnea, and wheezing. Examination reveals cyanosis, distended neck veins, and a prominent epigastric pulsation. What is the most likely diagnosis?
A
cor pulmonale
B
chronic bronchitis
C
emphysema
D
pneumonia
Question 1 Explanation: 
Cor pulmonale is right ventricular hypertrophy and failure resulting from pulmonary disease. It is most commonly caused by chronic obstructive pulmonary disease, which is this patient's underlying disorder precipitating the failure. While the other three diagnoses may have similar symptoms, none of them would present with distended neck veins and prominent epigastric pulsations.
Question 2
A 62-year-old woman with pulmonary hypertension called 911 complaining of sweating and difficulty in breathing. Upon arrival to her home the paramedics found her to have pallor, diaphoresis, tachypnea, hypotension, and tachycardia. Her pulse oximetry was 89%, so they gave her oxygen via nonrebreather mask and transported her to the emergency department (ED). She was not complaining of angina. The ED physician assistant noted her to be in acute distress with elevated jugular venous pressure, a medial heave, a tender palpable liver, a systolic murmur of tricuspid regurgitation, and an S4 gallop. ECG demonstrated right axis deviation and right ventricular hypertrophy with no ST-T changes. Her arterial blood gas (ABG) demonstrated a low PaO2 and a low PaCO2. What is her likely diagnosis?
A
acute coronary syndrome
Hint:
Marked hypotension in acute coronary syndrome occurs when the right coronary artery is affected. Acute coronary syndromes do not usually present with systolic murmurs, but patients will complain of angina and the ECG changes will include ST-segment changes.
B
cor pulmonale
C
heart failure
Hint:
Patients who have severe heart failure will have similar symptoms but also have pulsus alternans and pulmonary rales.
D
pulmonary embolus
Hint:
patients with pulmonary embolus may have hemodynamic changes but usually have a low PaO2 and a normal PaCO2. ECG may show right-axis deviation in a pulmonary embolus as well.
Question 2 Explanation: 
Patients with all of these conditions may be diaphoretic and complaining of dyspnea. Marked hypotension in acute coronary syndrome occurs when the right coronary artery is affected. Acute coronary syndromes do not usually present with systolic murmurs, but patients will complain of angina and the ECG changes will include ST-segment changes. Patients who have severe heart failure will have similar symptoms but also have pulsus alternans and pulmonary rales. Finally, patients with pulmonary embolus may have hemodynamic changes but usually have a low PaO2 and a normal PaCO2. ECG may show right-axis deviation in a pulmonary embolus as well.
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Pulmonary Circulation (PEARLS) (Prev Lesson)
(Next Lesson) Pulmonary embolism (ReelDx)
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