1/9 You hear an extra transient heart sound near S1. Now what?
(All sounds in this thread best heard with headphones/good speakers)
2/9 Not sure you hear three sounds? Here is normal S1 and S2 to serve as a control. There are two sounds. Listen to this clip and then re-listen to the above clip. When you do, you will hear three sounds. Two near where S1 should be, followed by S2.
3/9 So what's the differential for extra transient sounds near S1?
DDx:
Split S1
S4 gallop
Ejection click
4/9 Split S1 and S4 gallop can be challenging to distinguish because both are best heard over the APEX area. However, the split S1 sounds are closer together than the S1-S4 interval. And the S4 is best heard with the BELL of the scope. Listen to this split S1:
5/9 Now take a listen to this S4 gallop:
Notice that the S1-S4 interval is longer compared to the split S1 above. And while we are listening over the same area of the chest (apex), the bell is being used rather than the diaphragm.
6/9 What about the ejection click? It is perhaps the easiest to distinguish because it is best heard over the BASE of the heart - very atypical for the split S1 and S4. The click is best appreciated with the diaphragm of the scope as it is higher pitched.
7/9 So back to our patient. What is the extra sound?
It is heard over the base of the heart with the diaphragm. This is an ejection click.
(It was picked up on routine exam and led to the diagnosis of a severely dilated aortic root. Surgery is in 3 weeks.)
8/9 Remember that the exam is never performed in a vacuum. You will also have the benefit of the history and other findings. Does the patient have longstanding HTN (S4)? Does the patient have a giant a wave with an RV heave suggestive of pulmonary hypertension (click)?
1/9 A 70-year-old man presents with dyspnea. What do you notice when you first meet him?
This finding should generate a hypothesis, which we will circle back to eventually.
2/9 Before we do, let’s talk about dyspnea. The two main systems responsible for dyspnea are the heart and the lungs.
3/9 The jugular venous pulse can serve as a pivot point. It can take you toward or away from the heart. With this in mind, let’s evaluate the patient’s neck. Here, he is in the upright position. (Sometimes the jugular venous pulse is better seen on the left.)
1/8 A young man comes to our clinic for evaluation of rapid weight gain. He has heard "diet and exercise" several times before he sees us.
The driver license photo was taken ~9 months prior.
We make some observations, leading us to generate a hypothesis.
2/8
Based on our hypothesis, we examine the patient further. And we make several more important observations, increasing the likelihood of our hypothesis.
3/8
We remember that skin thickness can be an important sign in this condition, from Lynn Loriaux's 2017
@NEJM review.
(Examiner's hand is shown above, patient's below.)
1/8
A young man presents with dyspnea. We start with his hands.
My hand is gloved in the second photo (for frame of reference, I can palm a basketball).
Our patient has a finding that should generate a hypothesis.
2/8
Our hypothesis takes us to the patient’s mouth.
3/8
A high-arched palate. Otherwise note as an “ogival” arch. These arches are pointed at the top and are a key feature of Gothic architecture, beginning in the 12th century.
1/11
A 35 y/o woman presents with numbness and paresthesias in her feet and legs, imbalance, and frequent falls, progressing over a period of months.
Your astute med student notices high arched feet and bent toes. What do these findings suggest?
2/11
The history along with the presence of pes cavus (high arch) and hammertoes (toes bent at middle joint) suggest peripheral neuropathy (eg, polyneuropathy). Let’s perform a hypothesis-driven exam. What would we expect the reflexes to be like in a patient with polyneuropathy?
3/11
Our pt has brisk upper extremity reflexes and absent lower extremity reflexes. Polyneuropathy is usually length-dependent, beginning in the legs before affecting the arms.
Next, we’ll test sensation, starting with pain and temperature (small fiber, anterolateral cord).
1/11
A young woman presents with bleeding from her nose and gums and the following skin rash.
2/11
Petechiae are pinpoint hemorrhages <2 mm in size, purpura are 2 mm to 1 cm, and ecchymoses are >1 cm. Our patient has all three. These lesions are the result of extravasation of blood from the vasculature into skin/mucosa and do not blanch, as shown in this video:
3/11
A platelet disorder could explain these symptoms and physical findings.
But is the platelet issue qualitative (platelets are normal in number but abnormal in function) or quantitative (platelets are normal in function, but abnormal in number)?