In a patient with pulmonary hypertension, which physical exam finding is most characteristic?

• A. Opening snap
• B. Accentuation of the pulmonic component of the second heart sound
• C. Decreased jugular venous pressure
• D. No pitting edema

Answer: (B)

The key idea is that pulmonary hypertension increases pressure in the pulmonary arteries, so the right ventricle has to work harder to push blood through the lungs. This elevated afterload makes the pulmonic valve close more forcefully, producing a loud or accentuated pulmonic component of the second heart sound (P2). On exam you’ll often hear a pronounced P2 at the left upper sternal border, sometimes with a more prominent S2 overall, and it may be accentuated with inspiration.

Opening snap is a sound from mitral stenosis as the mitral valve opens early in diastole, not related to the pulmonary valve or elevated pulmonary pressures. A decreased jugular venous pressure would be unusual here because pulmonary hypertension often leads to signs of right-sided pressure overload, including elevated JVP. Edema can occur with right heart failure from prolonged pulmonary hypertension, so the absence of edema isn’t a characteristic feature.