Correspondence

Undercover and Overlooked

N Engl J Med 2004; 351:2881December 30, 2004

Article

To the Editor:

Wang and Bashore's statement that physical examination provided “little guidance” in the case described in their Clinical Problem-Solving article (Sept. 2 issue)1 is challenging in its omissions. Admittedly, the patient's extreme obesity made physical examination difficult. Nevertheless, a finding of pulsus paradoxus may have suggested that pericardial constriction was present, as later proved to be the case. Inspecting the neck while the patient is sitting or standing sometimes reveals the jugular column, which may otherwise be hidden by other neck structures or by the ears when the elevation in venous pressure is extreme. Even in a patient with a fat abdomen, epigastric and right-upper-quadrant tenderness may suggest the presence of liver congestion due to heart failure or constrictive pericarditis. These points might have brought the heart into focus sooner than was the case.

Mark N. Lowenthal, M.B.
Ben Gurion University, Beer Sheva 84105, Israel
markll@bgumail.bgu.ac.il

Alexander Lowenthal, M.D.
Schneider Children's Hospital, Petach Tikva 49202, Israel

1 References

1. 1

   Wang A, Bashore TM. Undercover and overlooked. N Engl J Med 2004;351:1014-1019
   Full Text | Web of Science | Medline

Author/Editor Response

We concur that careful assessment of the jugular venous pressure is important for determining whether heart failure may be the cause of a patient's dyspnea. The suggested methods of physical examination are appropriate and may be helpful for discerning whether the jugular venous pressure is elevated (i.e., whether the top of the jugular venous column is more than 3 cm above the sternal angle in any position1), particularly in cases in which visualization of the jugular venous pressure is challenging. Because the patient discussed in our article was initially evaluated at other centers, we do not know whether these methods were used.

However, despite careful physical examination, the diagnosis of heart failure as the cause of dyspnea may still be challenging. Whereas many symptoms or signs may individually suggest heart failure as the cause of dyspnea, validated diagnostic criteria for heart failure, such as the Framingham criteria,2 rely on a combination of these findings. Furthermore, as illustrated in a recent clinical trial, findings on physical examination have low accuracy for detecting heart failure in patients with dyspnea of unknown cause, in comparison with other methods such as chest radiography and measurement of B-type natriuretic peptide levels.3

Andrew Wang, M.D.
Thomas M. Bashore, M.D.
Duke University Medical Center, Durham, NC 27710

3 References

1. 1

   McGee SR. Physical examination of venous pressure: a critical review. Am Heart J 1998;136:10-18
   CrossRef | Web of Science | Medline

2. 2

   McKee PA, Castelli WP, McNamara PM, Kannel WB. The natural history of congestive heart failure: the Framingham Study. N Engl J Med 1971;285:1441-1446
   Full Text | Web of Science | Medline

3. 3

   Maisel AS, McCord J, Nowak RM, et al. Bedside B-type natriuretic peptide in the emergency diagnosis of heart failure with reduced or preserved ejection fraction: results from the Breathing Not Properly Multinational Study. J Am Coll Cardiol 2003;41:2010-2017
   CrossRef | Web of Science | Medline