1/9
A 33 y/o F with carpal tunnel syndrome presents with polyuria and polydipsia. She has a fasting serum glucose of 212 mg/dL and a hemoglobin a1c of 9.7%.

Do you have an approach to hyperglycemia? 2/9
The first step is to determine whether we are dealing with insulin-dependent hyperglycemia or insulin-independent hyperglycemia.

1/10
A young man presents with hematuria and is found to have these painful skin lesions on physical exam.
2/10
In a patient with hematuria, the first question I always ask is: what is the source of that blood?

Is it glomerular or non-glomerular?

1/9
A man presents with weakness.

Let’s walk through an approach to this problem. 2/9
The etiologies of weakness can be subdivided into 4 main categories:

1/10
A 76 y/o man presents with swallowing difficulty.

So why are we looking at his hands? 2/10
What’s your approach to dysphagia?

The first thing we want to determine is whether dysphagia is oropharyngeal or esophageal.

1/11
A physical exam SMASLAR in 11 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: 2/11
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

1/11
A man presents to you with the clinical syndrome of heart failure (weight gain, orthopnea, elevated JVP, etc.). BP is 144/48 mm Hg.

Wide pulse pressure suggests aortic regurgitation (like our case last week). So you look for other physical findings. What do you notice? 2/11
Quincke’s pulse is consistent with your hypothesis, so you look for more evidence in his neck. And you have found it.

Corrigan's pulse:

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.

1/10
I was in the hospital with a group of students when a cardiologist spotted us. “Go see the patient in such and such room, you might like his exam.”

So we go in blind.

We notice that he’s young (30s). Next, we examine the neck. Here he is in the upright position. 2/10
JVP is elevated and Kussmaul's sign is present. Normally the JVP goes down with inspiration. . .

In addition to Kussmaul's sign, there is a second qualitative finding, better seen in this video. What part of the waveform catches your eye? Outward or inward?

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.