1/8 A 50-y/o man presents with exertional dyspnea. The two main systems responsible for dyspnea are the heart and the lungs.
2/8 The jugular venous pulse can serve as a pivot point. It can take you toward or away from the heart. With this in mind, you evaluate the patient's neck. What do you notice?
Not only is the JVP elevated, but it appears to rise with inspiration. This is known as Kussmaul's sign
3/8 In the above video, you may have also noticed a mark on the patient's skin, just below the "a wave" in our logo. Here is the mark up close:
What is it?
4/8 You ask the patient when he had radiation therapy to his chest, and he gives you a surprised look. "How did you know?"
5/8 "I haven't thought about it in 30 years. I had Hodgkin's lymphoma when I was 17 years old. They shot radiation at my chest. Why does it matter, doc?"
6/8 Next, you listen to the patient's heart, anticipating what you might hear.
"The ears can't hear what the mind doesn't know"
7/8 You hear an extra transient sound near S2. Your differential is split S2, S3 gallop, opening snap, and pericardial knock.
The location, pitch, distance from S2, and the associated history and JVP findings make this sound most likely to be a pericardial knock.
8/8 You diagnose this patient with radiation-induced constrictive pericarditis. With your eyes and ears.
The effects of radiation therapy can show up decades later, when patients have all but forgotten they even had it.
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:
2/11
Here's another view of these vigorous carotid pulses (Corrigan's pulse). Classically associated with aortic regurgitation (like we saw 2 weeks ago), there are several other causes:
1. High-output state (eg, wet beriberi) like we saw last week 2. Coarctation of the aorta
3/11
I immediately think he must have aortic regurgitation. I listen, but I don't hear a diastolic murmur.
Still, I evaluate his nail beds and this is what I see:
1/10
A 60 y/o woman presents with subacute, progressive, severe hyponatremia (Na 118).
Let’s walk through an approach to this common problem.
2/10
First we confirm we are dealing with hypotonic hyponatremia.
This begins to narrow our differential.
3/10
Next we want to know the status of extracellular fluid volume. Our patient has low JVP, no peripheral edema, and dry mucous membranes, narrowing our differential even further.
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.