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.
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?
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:
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.
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.