1/
A physical exam SMASLAR in 10 tweets.
This middle-age patient was admitted several weeks ago with cardiogenic shock of unclear etiology. He is recovering well on the ward when I meet him. This is what I see:
A physical exam SMASLAR in 10 tweets.
This middle-age patient was admitted several weeks ago with cardiogenic shock of unclear etiology. He is recovering well on the ward when I meet him. This is what I see:
2/
Here is another view of these vigorous carotid pulses (Corrigan's pulse). Classically associated with aortic insufficiency, there are several other causes:
1. High-output state (eg, wet beriberi, thyrotoxicosis, etc.)
2. Coarctation of the aorta
Here is another view of these vigorous carotid pulses (Corrigan's pulse). Classically associated with aortic insufficiency, there are several other causes:
1. High-output state (eg, wet beriberi, thyrotoxicosis, etc.)
2. Coarctation of the aorta
3/
I immediately think he must have aortic insufficiency. I listen, but I do not hear a diastolic murmur. Still, I evaluate his nail beds and this is what I see:
I immediately think he must have aortic insufficiency. I listen, but I do not hear a diastolic murmur. Still, I evaluate his nail beds and this is what I see:
4/
Yes. Quincke's pulse. Must be AI right? I review his echo with cards and he does have a bicuspid aortic valve along with AI, but only mild. Not enough to explain these findings. LVEF has also recovered. Could this be high-output HF given that he presented w cardiogenic shock?
Yes. Quincke's pulse. Must be AI right? I review his echo with cards and he does have a bicuspid aortic valve along with AI, but only mild. Not enough to explain these findings. LVEF has also recovered. Could this be high-output HF given that he presented w cardiogenic shock?
5/
A cardiac MRI is performed to evaluate his underlying cardiomyopathy. No evidence of high-output HF. But what is there evidence of? What goes along with bicuspid aortic valve and Corrigan's pulse? And what should I have already diagnosed?
He has coarctation of the aorta.
A cardiac MRI is performed to evaluate his underlying cardiomyopathy. No evidence of high-output HF. But what is there evidence of? What goes along with bicuspid aortic valve and Corrigan's pulse? And what should I have already diagnosed?
He has coarctation of the aorta.
6/
I had all I needed to make this diagnosis before the cardiac MRI, but I was fixated on high-output HF and didn't think to consider coarctation as the cause of the vigorous carotid pulses I noticed. I retrospectively evaluate for radial-femoral pulse delay (turn sound on):
I had all I needed to make this diagnosis before the cardiac MRI, but I was fixated on high-output HF and didn't think to consider coarctation as the cause of the vigorous carotid pulses I noticed. I retrospectively evaluate for radial-femoral pulse delay (turn sound on):
7/
It is perhaps the most obvious example I have ever felt. Not sure you hear the delay? Here is a "control", with the Doppler probes over both radial arteries, which pulsate at the exact same time:
It is perhaps the most obvious example I have ever felt. Not sure you hear the delay? Here is a "control", with the Doppler probes over both radial arteries, which pulsate at the exact same time:
8/
The radial and femoral arteries should also pulsate at the exact same time, but there is a clear delay. I should have diagnosed aortic coarctation with my eyes and hands alone (especially given bicuspid valve). No need for a fancy cardiac MRI at a few thousand dollars a turn.
The radial and femoral arteries should also pulsate at the exact same time, but there is a clear delay. I should have diagnosed aortic coarctation with my eyes and hands alone (especially given bicuspid valve). No need for a fancy cardiac MRI at a few thousand dollars a turn.
9/
So what is SMASLAR? It stands for "Shoveling Manure And Smelling Like A Rose". My high school math teacher used to write it on our tests when we arrived at the correct answer but our steps toward solving the problem were wrong. You sort of stumble your way to the answer.
So what is SMASLAR? It stands for "Shoveling Manure And Smelling Like A Rose". My high school math teacher used to write it on our tests when we arrived at the correct answer but our steps toward solving the problem were wrong. You sort of stumble your way to the answer.
10/
In sum:
1. Think about coarctation when you see Corrigan's and/or Quincke's pulse
2. I've never seen coarctation listed in the differential for Quincke's but it absolutely should be
3. Coarctation can present in adulthood
4. Don't SMASLAR your way to the diagnosis like I did
In sum:
1. Think about coarctation when you see Corrigan's and/or Quincke's pulse
2. I've never seen coarctation listed in the differential for Quincke's but it absolutely should be
3. Coarctation can present in adulthood
4. Don't SMASLAR your way to the diagnosis like I did
Someone asked about rib notching (@DrGalenMD I think). This patient had 9 chest x-rays at our institution alone (and presumably more prior to transfer). It is easier to produce findings retrospectively:
(This should have been diagnosed clinically. Next time I will.)
(This should have been diagnosed clinically. Next time I will.)
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