1/11
A 55 y/o man presents for evaluation of chronic diarrhea. We walk into the room to meet him.
We have an opportunity to make an “augenblick” diagnosis – one that can be made in the blink of an eye.
2/11
We listen to his heart to help confirm our hypothesis (best with headphones). There is a holosystolic murmur over the LLSB. Notice that the intensity of the murmur seems to vary in a regular cycle? It gets louder/quieter/louder/quieter. What is the significance of this?
3/11
The augmentation of the murmur during inspiration is known as Carvallo’s sign, and indicates that the abnormal heart sound is coming from the R-side of the heart. Here is a more dramatic example in a different patient with tricuspid stenosis:
4/11
Our patient has tricuspid regurgitation. We’ve made a diagnosis, but does it end there? No. We must now determine the cause of the TR.
Similar to the “diagnosis” of anemia. . .we don’t stop there, we must determine the underlying cause.
So what is the cause of TR here?
5/11
Let’s get back to the chief complaint of diarrhea. Is there a tie-in with tricuspid regurgitation? We consult our framework for diarrhea:
6/11
The diarrhea is chronic and non-bloody, making infectious (and other inflammatory) causes less likely.
7/11
Additional history reveals that the diarrhea occurs up to 15 times per day, and persists even during periods when he does not eat. These features suggest a secretory cause.
8/11
Is there a cause of secretory diarrhea in the framework that can be associated with tricuspid valve regurgitation? Yes there is.
9/11
Vasoactive substances released by carcinoid tumors can damage the heart valves, leading to stenosis and/or regurgitation. Left-sided valves are spared in most cases because the lungs inactivate the vasoactive substances before they reach the left side of the heart.
10/11
Octreotide scan shows areas of normal radiotracer uptake (bladder, kidneys, spleen), but there is a focus of increased uptake in the region of the small intestine (the primary tumor site), and multiple globular foci of increased uptake in the liver (mets).
11/11
First, we diagnosed TR with our eyes only. An augenblick diagnosis.
Next, we used the diarrhea framework to identify a connection to TR, leading to hypothesis-driven confirmation.
For more cases: physicaldiagnosispdx.com/case-presentat…
For more frameworks: amazon.com/Frameworks-Int…
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