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.

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.

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.

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?

1/11
A young man presents with hematuria and is found to have these painful skin lesions on physical exam. 2/11
In a patient with hematuria, the first question I always ask is as follows: what is the source of that blood?

Is it glomerular or non-glomerular?

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:

1/11
A 44 y/o man presents with acute abdominal pain, vomiting, and diarrhea. HR 130, BP 90/52. We walk into the room to meet the patient. What do you notice? This should generate at least one hypothesis. 2/11
We ask the patient for an old photograph for comparison. His wife pulls out her phone and produces this picture (B) taken about 10 years prior. Pt reports darkening of skin over an 8 year period. What conditions should we consider?

1/8
A young man is admitted to the hospital with malaise and fever. We examine his hands and feet and find these nontender hemorrhagic macules. 2/8
This should generate a hypothesis.

With our hypothesis in mind, we listen to the patient’s heart. We anticipate what we might hear. “The ears can’t hear what the mind doesn’t know.”

(For best listening experience play on a device with good speakers.)

1/10
A middle-age man presents with dyspnea on exertion, orthopnea, and weight gain. His BP is 112/40. This should generate a hypothesis. And we begin to test our hypothesis by evaluating for specific physical findings. What clue is present in this video? 2/10
The presence of de Musset’s sign (to-and-fro head bob) is consistent with our hypothesis. So we look for more evidence.

1/12
A 58 y/o man presents with dyspnea.

We are struck by the appearance of his hands. 2/12
We ignore the hands for a moment and recall that most cases of dyspnea are primarily related to either the heart or the lungs (or both).

1/17
Recently finished service. Here are some of the physical findings my team and I saw in 7 days.

Starting with a classic. 2/17
Kussmaul's sign. I was once told I'd see it a few times in my career. I see it every day.

This patient also has an S3 gallop. (Turn sound up.)

He was admitted with decompensated heart failure.

1/5
@PeteSullivanPDx and I need help with a patient. Never seen anything like it.

In short, there is severe hepatic protein synthesis dysfunction in the absence of cirrhosis, 60 y/o M.

Hepatologists, geneticists, protein biochemists, others?

Please read on for details. 2/5
Presents with anasarca developing over years, now much worse x4-5 weeks. Has severe hypoalbuminemia (album 1.0). No proteinuria. No stool loss (stool alpha-1 <5, low clearance). Not malnourished. Nodular liver on imaging but no cirrhosis x2 biopsies, no portal hypertension.

1/14
A young Lebanese man presents with several days of chest pain.

Let’s remind ourselves where Lebanon is on the map. It may prove valuable "down the road".

(Graphic courtesy freeworldmaps. net.) 2/14
Now let's deal with his chest pain. It can be helpful to think of chest pain as either cardiac or noncardiac in nature. The history and exam will point you down one "road" or the other.

1/19
A middle-aged man presents with acute sudden-onset dyspnea and hypotension. He is sitting upright. What do you notice? Let’s see if we can figure out the cause of hypotension. 2/19
First.

What are the 4 basic mechanisms of hypotension?

Hypotension can be hypovolemic, cardiogenic, distributive, or obstructive.

1/10
Doctors and nurses are often asked to create “rules” for hospitalized patients with behavioral concerns, including limitations on leaving the unit, being subject to a body search on return, and limitations on visitors.

Here’s why I think that’s a bad idea. 2/10
We can all agree that disruptive behaviors can impact care in a negative way. Imagine we are treating a patient with endocarditis for weeks in the hospital with IV antibiotics. If this patient is using elicit IV drugs during the hospitalization, that is clearly a problem.

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.

1/11
A 55 y/o man presents for evaluation of chronic diarrhea. We walk into the room to meet him.

We have an opportunity to make an “augenblick” diagnosis – one that can be made in the blink of an eye. 2/11
We listen to his heart to help confirm our hypothesis (best with headphones). There is a holosystolic murmur over the LLSB. Notice that the intensity of the murmur seems to vary in a regular cycle? It gets louder/quieter/louder/quieter. What is the significance of this?

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.

1/10
A 26 y/o woman presents with migratory arthritis. Started with a red and hot foot/ankle. Then went to the knee. Overuse, she was told. When ice/rest did not help, she went to the hospital.

An arthrocentesis procedure was performed. 2/10
20K white blood cells but no organisms. She was taken for a washout procedure for presumed septic arthritis.

And when the knee didn't improve, she was taken for another one.

And when she still didn't improve, she was transferred to our hospital.

1/8
You are rotating on the Procedure Service and your team is asked to perform a routine "therapeutic" paracentesis on a patient with cancer. You walk into the room to meet the patient and this is what you see.

This finding should generate a hypothesis. 2/8
A "diagnostic" paracentesis wasn't requested, but the underlying cause of ascites in this case has never been questioned. You consult your framework for ascites:

The first question you want to know is whether the process is driven by portal hypertension or not.

1/12
A man presents to you with the clinical syndrome of heart failure (weight gain, orthopnea, elevated JVP, etc.). BP is 144/48 mm Hg.

This should generate a hypothesis. Yoo you look for other specific physical findings. What do you notice in this video? 2/12
Quincke's pulse is consistent with your hypothesis, so you look for more evidence in his neck. And you have found it.