Recognize pulmonary hypertension on exam: loud P2 plus inspiratory holosystolic TR murmur signals RV strain and advanced disease.
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A loud/accenuated P2 plus a tricuspid regurgitation holosystolic murmur strongly suggests clinically significant pulmonary hypertension with right-sided strain.
A 43-year-old woman presents with the complaint of shortness of breath on exertion. She states that this symptom began insidiously about 2 years ago and has become progressively worse. Over the past 6 weeks, it occurs even with mild activity, such as dressing herself, and she has also noted swelling of her feet and ankles. The only other symptom has been general fatigue. Her past health is excellent. She played tennis regularly until about 18 months ago when she stopped because of shortness of breath. She has not had chest or abdominal pain, cough, or shortness of breath when supine. She takes no medications, does not smoke cigarettes, and enjoys 1 glass of wine in the evening. Physical examination shows a woman who is comfortable at rest. Vital signs are: blood pressure 130/80 mm Hg (right arm), pulse 82 beats/minute and regular, respiratory rate 14 breaths/minute, temperature 98.4°F , and oxygen saturation on room air 94%. Neck veins are moderately distended. The lungs are clear. Cardiac examination reveals a loud second sound at the right sternal border and a grade 2 holosystolic murmur along the left sternal border that increases with inspiration. There is 2+ soft pitting edema of the feet and ankles. Laboratory studies include a complete blood count, electrolytes, liver function studies, and blood urea nitrogen and creatinine levels. All of the laboratory values are normal. Electrocardiography shows right ventricular hypertrophy with a strain pattern.
Which of the following findings would be diagnostically suggestive of pulmonary hypertension in this patient?
This stem already gives you the two most board-reliable exam clues to pulmonary hypertension that has progressed to right-sided dysfunction: (1) an accentuated P2 (reflecting elevated pulmonary artery pressure) and (2) a holosystolic murmur that increases with inspiration (classic for tricuspid regurgitation, i.e., Carvallo sign), which commonly develops as the RV dilates/fails in more advanced disease.
Current consensus guidelines (e.g., ESC/ERS 2022) emphasize that diagnosis is confirmed hemodynamically (right heart catheterization), but physical exam remains a high-yield screening/recognition tool: loud P2, TR murmur, JVP elevation, and peripheral edema all cluster in significant pulmonary hypertension with right heart failure.
| Option | What It Tests / Implies | Why It’s Wrong Here |
|---|---|---|
| loud pulmonic second sound | Recognizing accentuated P2 as PH clue | True but incomplete vs the best-supported combined finding in this patient with RV strain + edema/JVP. |
| loud pulmonic second sound and holosystolic murmur | PH with elevated PA pressure plus functional TR from RV dilation | Best match to the stem (accentuated P2 + inspiratory holosystolic TR murmur + RVH/strain + right HF signs). |
| holosystolic murmur | Identifying TR (or confusing with MR) | TR alone suggests right-sided pathology but does not specifically anchor pulmonary hypertension without the accentuated P2 clue. |
| enlarged liver | Congestive hepatopathy from right HF | Nonspecific; occurs in many causes of right HF and does not point to pulmonary hypertension as the etiology. |
In progressive pulmonary hypertension, accentuated P2 + TR holosystolic murmur (louder with inspiration) is a classic exam pairing that tracks with RV dilation/failure.
This is a “best next recognizing finding” question: multiple options are individually plausible, but boards reward selecting the option that integrates severity and mechanism. The stem already shows advanced physiology (JVD, edema, RVH/strain), so the best answer is the combined exam findings that fit pulmonary hypertension progressing to functional TR.
A 38-year-old patient has exertional dyspnea and a holosystolic murmur best heard at the left lower sternal border that becomes louder with inspiration. What lesion is most consistent with this finding?
Which physical exam finding most directly reflects elevated pulmonary artery pressure in pulmonary hypertension?
A patient with progressive exertional dyspnea has suspected pulmonary hypertension on exam. What is the preferred initial noninvasive test to estimate pulmonary pressures?
After echocardiography suggests pulmonary hypertension, what test confirms the diagnosis and characterizes hemodynamics?
How would your differential and initial workup change if this patient had significant interstitial lung disease on exam/imaging or had orthopnea and bibasilar crackles suggesting left-sided heart failure (postcapillary pulmonary hypertension)?
Q1: What physical exam findings most strongly suggest pulmonary hypertension on boards?
A: The ABFM/ABIM commonly expect recognition of accentuated P2, RV heave, and (in more advanced disease) a TR murmur with right-sided congestion signs.
Q2: Can you diagnose pulmonary hypertension from physical exam alone?
A: No—exams test that you suspect it clinically, then confirm with echocardiography (screening/estimate) and right heart catheterization (definitive), consistent with ESC/ERS 2022.
Q3: Why does tricuspid regurgitation show up in pulmonary hypertension?
A: Chronic RV pressure overload leads to RV dilation and annular dilation, producing functional TR (holosystolic murmur, louder with inspiration).
Q4: Why isn’t hepatomegaly the best diagnostic clue?
A: Boards treat hepatomegaly as a downstream sign of systemic venous congestion that does not localize the cause; loud P2/TR murmur points upstream to pulmonary vascular/RV pathology.
This question appears in Med-Challenger Internal Medicine Review with CME
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