1/6
A young man is admitted to the hospital with malaise and fever. You examine his hands and find these tender nodules.

This should generate a hypothesis.

(Heart sounds in this thread best heard with headphones or a decent computer speaker)
2/6
With your hypothesis in mind, you listen to the patient's heart. You anticipate what you might hear.

"The ears can't hear what the mind doesn't know."
3/6
Based on the holosystolic murmur at the apex that you anticipated you would hear, you diagnose the patient with mitral valve endocarditis. Two days later, his heart sounds change. Take a listen.

An additional diagnosis has now been made.
4/6
Two days later, you know longer hear the pericardial friction rub. In fact, his heart sounds are difficult to hear at all. He develops hypotension and pre-syncope and his neck looks like this:

This should generate a hypothesis.
5/6
You confirm your hypothesis with a bedside maneuver (video features a different patient with the same diagnosis):
6/6
You have diagnosed infective endocarditis of the mitral valve with pericardial involvement, evolving to pericardial effusion with cardiac tamponade. All with your eyes and ears.

pdxpdx.com

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More from @AndreMansoor

31 Dec 21
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
Read 9 tweets
27 Dec 20
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:
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
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:
Read 11 tweets
5 Jan 20
1/

On the subject of paracentesis.
2/

There are 2 main components to all procedures: cognitive aspects (indications, contraindications, complications) and technical aspects (steps of procedure, hand positioning, etc.).

Let’s start with the cognitive aspects.
3/

Indications. As with most procedures there are 2 broad indications: diagnostic and therapeutic. In order to understand the nature of the fluid and approach the broad differential diagnosis, it must be sampled. Portal HTN vs non-portal HTN. Also eval for SBP.
Read 23 tweets
29 Dec 19
1/

On the subject of thoracentesis.
2/

There are 2 main components to all procedures: cognitive aspects (indications, contraindications, complications) and technical aspects (steps of procedure, hand positioning, etc.).

Let’s start with the cognitive aspects.
3/

Indications. As with most procedures there are 2 broad indications: diagnostic and therapeutic. In order to understand the nature of the fluid and approach the broad differential diagnosis, it must be sampled. Transudate vs exudate.
Read 24 tweets

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