1/8 A young woman presents with progressive dyspnea. You walk into the room and this is what you see.
What finding is present?
2/8 Central cyanosis indicates the presence of hypoxemia. SPO2 by pulse oximetry is 80%. ABG on room air shows PaO2 of 40 mm Hg and PaCO2 of 30 mm Hg.
We reference our framework for hypoxemia to begin the process of narrowing our differential diagnosis.
3/8 The first thing we want to know is the A-a gradient.
A (from the alveolar gas equation) = 112 mm Hg
a (from the ABG) = 40 mm Hg
A-a = 112 - 40 = 72 mm Hg.
Elevated.
4/8 Next we revisit the physical examination for more clues. There is profound peripheral cyanosis. But what else do you notice?
If you don't specifically look for this finding you might never notice it. "The eyes can't see what the mind doesn't know."
5/8 Clubbing indicates that we are likely dealing with an anatomic shunt.
6/8 The patient's precordial movement shown here is suggestive of an intracardiac shunt. @PeteSullivanPDx teaches that the chest can move in this way when blood travels from a higher pressure chamber to a lower pressure chamber. In this case, from the right to the left.
7/8 Our diagnosis is confirmed with an echo with agitated saline contrast. Bubbles appear in the LV within 3 beats.
Bubbles are normally filtered by the lungs. They only appear in the L side of the heart if there is an intracardiac (few beats) or intrapulmonary shunt (>5 beats).
8/8 We diagnosed an intracardiac shunt with our eyes, a Q-tip, and a few specific hypothesis-driven tests.
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.