{"id":11020,"date":"2022-02-02T18:47:08","date_gmt":"2022-02-03T02:47:08","guid":{"rendered":"https:\/\/up.physicaldiagnosispdx.com\/up\/?page_id=11020"},"modified":"2022-02-17T14:55:09","modified_gmt":"2022-02-17T22:55:09","slug":"case-presentations","status":"publish","type":"page","link":"https:\/\/up.physicaldiagnosispdx.com\/up\/case-presentations\/","title":{"rendered":"Case Presentations"},"content":{"rendered":"<div class=\"wpb-content-wrapper\">[vc_row css=&#8221;.vc_custom_1592017154846{background-color: #fff9f9 !important;}&#8221;][vc_column][vc_column_text]\n<p><span style=\"font-size: 14pt;\">Here you will find cases in which physical examination played a key role in making the diagnosis. Try to work through the cases one step at a time and see if you arrive at the correct diagnosis.<\/span><\/p>\n<p>&nbsp;<\/p>\n<p><img decoding=\"async\" loading=\"lazy\" class=\"wp-image-1658 size-thumbnail\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/iconfinder_3_1250308-150x150.png\" alt=\"\" width=\"150\" height=\"150\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/iconfinder_3_1250308-150x150.png 150w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/iconfinder_3_1250308-300x300.png 300w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/iconfinder_3_1250308.png 512w\" sizes=\"auto, (max-width: 150px) 100vw, 150px\" \/>[\/vc_column_text][\/vc_column][\/vc_row][vc_row][vc_column][vc_column_text][vc_row][vc_column width=&#8221;1\/1&#8243;][vc_column_text]\n<h1>Patient 1:<\/h1>\n[\/vc_column_text][\/vc_column][\/vc_row][vc_row css=&#8221;.vc_custom_1592017173859{background-color: #dcd9dd !important;}&#8221;][vc_column][vc_column_text]\n<div class=\"css-1dbjc4n\">\n<div id=\"id__c36nq0b98k\" class=\"css-901oao r-1fmj7o5 r-37j5jr r-a023e6 r-16dba41 r-rjixqe r-bcqeeo r-bnwqim r-qvutc0\" dir=\"auto\" lang=\"en\"><span class=\"css-901oao css-16my406 r-poiln3 r-bcqeeo r-qvutc0\" style=\"font-size: 14pt;\">A middle-age man presents with dyspnea on exertion, orthopnea, and weight gain. His BP is 112\/40. This should generate a hypothesis. And you begin to test your hypothesis by evaluating for specific physical findings. What do you notice in this video?<\/span><\/div>\n<\/div>\n<div dir=\"auto\" lang=\"en\"><\/div>\n<p style=\"text-align: center;\"><iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/472326971?loop=1\" width=\"320\" height=\"550\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\">&amp;lt;span data-mce-type=&#8221;bookmark&#8221; style=&#8221;display: inline-block; width: 0px; overflow: hidden; line-height: 0;&#8221; class=&#8221;mce_SELRES_start&#8221;&amp;gt;&amp;lt;\/span&amp;gt;<\/iframe><\/p>\n<p><span style=\"font-size: 14pt;\">The presence of de Musset&#8217;s sign (to-and-fro head bob) is consistent with your hypothesis. So you look for more evidence.<\/span><\/p>\n<p style=\"text-align: center;\"><iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/472432602?loop=1\" width=\"320\" height=\"550\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\">&lt;span data-mce-type=&#8221;bookmark&#8221; style=&#8221;display: inline-block; width: 0px; overflow: hidden; line-height: 0;&#8221; class=&#8221;mce_SELRES_start&#8221;&gt;\ufeff&lt;\/span&gt;<\/iframe><\/p>\n<p><span style=\"font-size: 14pt;\">And you find it in the form of Corrigan\u2019s pulse.\u00a0<\/span><span style=\"font-size: 14pt;\">You continue to evaluate the peripheral pulses and find more evidence to support your hypothesis.\u00a0<\/span><\/p>\n<p style=\"text-align: center;\"><iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/472433072?loop=1\" width=\"320\" height=\"550\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\">&amp;amp;lt;span data-mce-type=&#8221;bookmark&#8221; style=&#8221;display: inline-block; width: 0px; overflow: hidden; line-height: 0;&#8221; class=&#8221;mce_SELRES_start&#8221;&amp;amp;gt;\ufeff&amp;amp;lt;\/span&amp;amp;gt;<\/iframe><\/p>\n<p><span style=\"font-size: 14pt;\"><span class=\"TextRun Highlight SCXW56797988 BCX4\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"none\"><span class=\"NormalTextRun SCXW56797988 BCX4\">This should make it easier to appreciate.<\/span><\/span><span class=\"EOP SCXW56797988 BCX4\" data-ccp-props=\"{}\">\u00a0<\/span><\/span><\/p>\n<p style=\"text-align: center;\"><iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/472433660?loop=1\" width=\"320\" height=\"550\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\">&amp;lt;span data-mce-type=&#8221;bookmark&#8221; style=&#8221;display: inline-block; width: 0px; overflow: hidden; line-height: 0;&#8221; class=&#8221;mce_SELRES_start&#8221;&amp;gt;\ufeff&amp;lt;\/span&amp;gt;<\/iframe><\/p>\n<p><span style=\"font-size: 14pt;\"><span class=\"TextRun Highlight SCXW52559652 BCX4\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"none\"><span class=\"NormalTextRun SCXW52559652 BCX4\">Next you look at the patient&#8217;s fingernails. What do you see?<\/span><\/span><span class=\"EOP SCXW52559652 BCX4\" data-ccp-props=\"{}\">\u00a0<\/span><\/span><\/p>\n<p style=\"text-align: center;\"><iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/472331928?loop=1\" width=\"640\" height=\"360\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\">&lt;span data-mce-type=&#8221;bookmark&#8221; style=&#8221;display: inline-block; width: 0px; overflow: hidden; line-height: 0;&#8221; class=&#8221;mce_SELRES_start&#8221;&gt;\ufeff&lt;\/span&gt;<\/iframe><\/p>\n<p><span style=\"font-size: 14pt;\"><span class=\"TextRun Highlight SCXW22491617 BCX4\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"none\"><span class=\"NormalTextRun SCXW22491617 BCX4\">The patient is having trouble seeing what you see in his nail bed. <\/span><span class=\"NormalTextRun ContextualSpellingAndGrammarErrorV2 SCXW22491617 BCX4\">So<\/span><span class=\"NormalTextRun SCXW22491617 BCX4\"> you use a light source to help him.<\/span><\/span><span class=\"EOP SCXW22491617 BCX4\" data-ccp-props=\"{}\">\u00a0<\/span><\/span><\/p>\n<p style=\"text-align: center;\"><iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/472344243?loop=1\" width=\"320\" height=\"550\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\">&lt;span data-mce-type=&#8221;bookmark&#8221; style=&#8221;display: inline-block; width: 0px; overflow: hidden; line-height: 0;&#8221; class=&#8221;mce_SELRES_start&#8221;&gt;\ufeff&lt;\/span&gt;<\/iframe><\/p>\n<p><span style=\"font-size: 14pt;\"><span class=\"TextRun Highlight SCXW67130398 BCX4\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"none\"><span class=\"NormalTextRun SCXW67130398 BCX4\">You continue to evaluate the peripheral pulses, finally reaching his foot:<\/span><\/span><span class=\"EOP SCXW67130398 BCX4\" data-ccp-props=\"{}\">\u00a0<\/span><\/span><\/p>\n<p style=\"text-align: center;\"><iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/472433173?loop=1\" width=\"320\" height=\"550\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\">&amp;amp;lt;span data-mce-type=&#8221;bookmark&#8221; style=&#8221;display: inline-block; width: 0px; overflow: hidden; line-height: 0;&#8221; class=&#8221;mce_SELRES_start&#8221;&amp;amp;gt;\ufeff&amp;amp;lt;\/span&amp;amp;gt;<\/iframe><\/p>\n<p><span style=\"font-size: 14pt;\"><span class=\"TextRun Highlight SCXW21472493 BCX4\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"none\"><span class=\"NormalTextRun SCXW21472493 BCX4\">Before you even listen to the patient&#8217;s heart, your diagnosis has all but been made. And when you listen, you know exactly what to listen for. &#8220;The ears can&#8217;t hear what the mind doesn&#8217;t know&#8221;<\/span><\/span><span class=\"EOP SCXW21472493 BCX4\" data-ccp-props=\"{}\">\u00a0<\/span><\/span><\/p>\n<p style=\"text-align: center;\"><iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/463370763?loop=1 \" width=\"640\" height=\"291\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\">&amp;lt;span data-mce-type=&#8221;bookmark&#8221; style=&#8221;display: inline-block; width: 0px; overflow: hidden; line-height: 0;&#8221; class=&#8221;mce_SELRES_start&#8221;&amp;gt;\ufeff&amp;lt;\/span&amp;gt;<\/iframe><\/p>\n<p><span style=\"font-size: 14pt;\"><span class=\"TextRun Highlight SCXW241012893 BCX4\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"none\"><span class=\"NormalTextRun SCXW241012893 BCX4\">You have just diagnosed severe aortic insufficiency with your eyes, your ears, and a Q-tip.<\/span><\/span><span class=\"EOP SCXW241012893 BCX4\" data-ccp-props=\"{}\">\u00a0<\/span><\/span><\/p>\n<div id='gallery-1' class='gallery galleryid-11020 gallery-columns-3 gallery-size-medium'><figure class='gallery-item'>\n\t\t\t<div class='gallery-icon landscape'>\n\t\t\t\t<a href='https:\/\/up.physicaldiagnosispdx.com\/up\/fjvwkxpuuaemytz\/'><img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"106\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FJVWKxPUUAEMyTz-300x106.jpeg\" class=\"attachment-medium size-medium\" alt=\"\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FJVWKxPUUAEMyTz-300x106.jpeg 300w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FJVWKxPUUAEMyTz-1024x363.jpeg 1024w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FJVWKxPUUAEMyTz-768x273.jpeg 768w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FJVWKxPUUAEMyTz.jpeg 1178w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a>\n\t\t\t<\/div><\/figure>\n\t\t<\/div>\n\n[\/vc_column_text][\/vc_column][\/vc_row][vc_row][vc_column][vc_column_text]\n<h1>Patient 2:<\/h1>\n[\/vc_column_text][\/vc_column][\/vc_row][vc_row css=&#8221;.vc_custom_1592017173859{background-color: #dcd9dd !important;}&#8221;][vc_column][vc_column_text]\n<div class=\"css-1dbjc4n\">\n<div id=\"id__c36nq0b98k\" class=\"css-901oao r-1fmj7o5 r-37j5jr r-a023e6 r-16dba41 r-rjixqe r-bcqeeo r-bnwqim r-qvutc0\" dir=\"auto\" lang=\"en\"><span style=\"font-size: 14pt;\"><span class=\"TextRun Highlight SCXW251825559 BCX4\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"none\"><span class=\"NormalTextRun SCXW251825559 BCX4\">A young man is admitted to the hospital with malaise and fever. You examine his hands and find these tender nodules.\u00a0<\/span><\/span><span class=\"EOP SCXW251825559 BCX4\" data-ccp-props=\"{}\">\u00a0<\/span><\/span><\/div>\n<\/div>\n<div dir=\"auto\" lang=\"en\"><\/div>\n<p><span style=\"font-size: 14pt;\"><img decoding=\"async\" loading=\"lazy\" class=\"aligncenter size-medium wp-image-9568\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Infectious-Disease_Infective-Endocarditis_Oslers-Nodes_Oslers_Nodes-1-300x225.jpg\" alt=\"\" width=\"300\" height=\"225\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Infectious-Disease_Infective-Endocarditis_Oslers-Nodes_Oslers_Nodes-1-300x225.jpg 300w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Infectious-Disease_Infective-Endocarditis_Oslers-Nodes_Oslers_Nodes-1-1024x768.jpg 1024w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Infectious-Disease_Infective-Endocarditis_Oslers-Nodes_Oslers_Nodes-1-768x576.jpg 768w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Infectious-Disease_Infective-Endocarditis_Oslers-Nodes_Oslers_Nodes-1.jpg 1200w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/>This should generate a hypothesis.\u00a0<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">With your hypothesis in mind, you listen to the patient&#8217;s heart. You anticipate what you might hear. &#8220;The ears can&#8217;t hear what the mind doesn&#8217;t know.&#8221;\u00a0<\/span><\/p>\n<p style=\"text-align: center;\"><span style=\"font-size: 14pt;\" data-ccp-props=\"{}\"><iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/463366815?loop=1 \" width=\"640\" height=\"291\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/span><\/p>\n<p><span style=\"font-size: 14pt;\">An additional diagnosis has now been made. <\/span><\/p>\n<p>&nbsp;<\/p>\n<p><span style=\"font-size: 14pt;\"><span class=\"TextRun Highlight SCXW181960965 BCX4\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"none\"><span class=\"NormalTextRun SCXW181960965 BCX4\">Based on the holosystolic murmur at the apex that you anticipated you would <\/span><span class=\"NormalTextRun ContextualSpellingAndGrammarErrorV2 SCXW181960965 BCX4\">hear,<\/span><span class=\"NormalTextRun SCXW181960965 BCX4\"> you diagnose the patient with mitral valve endocarditis. Two days later, his heart sounds change. Take a listen.<\/span><\/span><span class=\"EOP SCXW181960965 BCX4\" data-ccp-props=\"{}\">\u00a0<\/span><\/span><\/p>\n<p>&nbsp;<\/p>\n<p style=\"text-align: center;\"><iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/463368618?loop=1 \" width=\"640\" height=\"291\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\">&lt;span data-mce-type=&#8221;bookmark&#8221; style=&#8221;display: inline-block; width: 0px; overflow: hidden; line-height: 0;&#8221; class=&#8221;mce_SELRES_start&#8221;&gt;\ufeff&lt;\/span&gt;&amp;amp;amp;lt;span data-mce-type=&#8221;bookmark&#8221; style=&#8221;display: inline-block; width: 0px; overflow: hidden; line-height: 0;&#8221; class=&#8221;mce_SELRES_start&#8221;&amp;amp;amp;gt;\ufeff&amp;amp;amp;lt;\/span&amp;amp;amp;gt;<\/iframe><\/p>\n<p><span style=\"font-size: 14pt;\" data-ccp-props=\"{}\">\u00a0<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">Two days later, you no 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:\u00a0<\/span><\/p>\n<p style=\"text-align: center;\"><iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/472340160?loop=1\" width=\"320\" height=\"550\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\">&amp;lt;span data-mce-type=&#8221;bookmark&#8221; style=&#8221;display: inline-block; width: 0px; overflow: hidden; line-height: 0;&#8221; class=&#8221;mce_SELRES_start&#8221;&amp;gt;\ufeff&amp;lt;\/span&amp;gt;<\/iframe><\/p>\n<p><span style=\"font-size: 14pt;\">This should generate a hypothesis.\u00a0<\/span><\/p>\n<p><span style=\"font-size: 14pt;\" data-ccp-props=\"{}\">\u00a0<\/span><span style=\"font-size: 14pt;\">You confirm your hypothesis with a bedside maneuver (video features a different patient with the same diagnosis):\u00a0<\/span><\/p>\n<p style=\"text-align: center;\"><iframe loading=\"lazy\" title=\"Pulsus Promo.mp4\" src=\"https:\/\/player.vimeo.com\/video\/649269709?h=3faf6c571b&amp;badge=0&amp;autopause=0&amp;player_id=0&amp;app_id=58479\" width=\"320\" height=\"550\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p><span style=\"font-size: 14pt;\"><span class=\"TextRun Highlight SCXW71649604 BCX4\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"none\"><span class=\"NormalTextRun SCXW71649604 BCX4\">You have diagnosed infective endocarditis of the mitral valve with pericardial involvement, evolving to pericardial <\/span><span class=\"NormalTextRun SCXW71649604 BCX4\">effusion with cardiac tamponade. All with your eyes and ears.<\/span><\/span><span class=\"EOP SCXW71649604 BCX4\" data-ccp-props=\"{}\">\u00a0<\/span><\/span>[\/vc_column_text][\/vc_column][\/vc_row][vc_row][vc_column][vc_column_text]\n<h1>Patient 3:<\/h1>\n[\/vc_column_text][\/vc_column][\/vc_row][vc_row css=&#8221;.vc_custom_1592017173859{background-color: #dcd9dd !important;}&#8221;][vc_column][vc_column_text]<span style=\"font-size: 14pt;\"><span class=\"TextRun Highlight SCXW15334807 BCX4\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"none\"><span class=\"NormalTextRun SCXW15334807 BCX4\">A middle-aged man walks into your clinic complaining of weakness. You take a moment to observe his gait. What do you notice?<\/span><\/span><\/span><\/p>\n<p style=\"text-align: center;\"><iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/472434143?loop=1\" width=\"320\" height=\"550\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\">&amp;lt;span data-mce-type=&#8221;bookmark&#8221; style=&#8221;display: inline-block; width: 0px; overflow: hidden; line-height: 0;&#8221; class=&#8221;mce_SELRES_start&#8221;&amp;gt;\ufeff&amp;lt;\/span&amp;gt;<\/iframe><\/p>\n<p><span style=\"font-size: 14pt;\">This should generate a hypothesis.\u00a0<\/span><\/p>\n<p><span style=\"font-size: 14pt;\" data-ccp-props=\"{}\">\u00a0<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">You reference your framework for weakness and try to determine the location of the lesion to narrow your differential diagnosis. The patient&#8217;s gait has already provided a clue (spasticity).\u00a0<\/span><\/p>\n<div id='gallery-2' class='gallery galleryid-11020 gallery-columns-3 gallery-size-medium'><figure class='gallery-item'>\n\t\t\t<div class='gallery-icon landscape'>\n\t\t\t\t<a href='https:\/\/up.physicaldiagnosispdx.com\/up\/fjbgsvavqaqtdzu\/'><img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"158\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FJBGsvaVQAQtDZU-300x158.jpeg\" class=\"attachment-medium size-medium\" alt=\"\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FJBGsvaVQAQtDZU-300x158.jpeg 300w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FJBGsvaVQAQtDZU-1024x540.jpeg 1024w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FJBGsvaVQAQtDZU-768x405.jpeg 768w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FJBGsvaVQAQtDZU.jpeg 1239w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a>\n\t\t\t<\/div><\/figure><figure class='gallery-item'>\n\t\t\t<div class='gallery-icon landscape'>\n\t\t\t\t<a href='https:\/\/up.physicaldiagnosispdx.com\/up\/fjbhrkzvcaaapqt\/'><img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"134\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FJBHRKzVcAAaPQT-300x134.jpeg\" class=\"attachment-medium size-medium\" alt=\"\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FJBHRKzVcAAaPQT-300x134.jpeg 300w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FJBHRKzVcAAaPQT-1024x457.jpeg 1024w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FJBHRKzVcAAaPQT-768x343.jpeg 768w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FJBHRKzVcAAaPQT.jpeg 1124w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a>\n\t\t\t<\/div><\/figure>\n\t\t<\/div>\n\n<p><span style=\"font-size: 14pt;\"><span class=\"TextRun Highlight SCXW213722469 BCX4\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"none\"><span class=\"NormalTextRun ContextualSpellingAndGrammarErrorV2 SCXW213722469 BCX4\">So<\/span><span class=\"NormalTextRun SCXW213722469 BCX4\"> you check his reflexes next.<\/span><\/span><span class=\"EOP SCXW213722469 BCX4\" data-ccp-props=\"{}\">\u00a0<\/span><\/span><\/p>\n<p style=\"text-align: center;\"><iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/472286198?loop=1\" width=\"320\" height=\"550\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\">&amp;lt;span data-mce-type=&#8221;bookmark&#8221; style=&#8221;display: inline-block; width: 0px; overflow: hidden; line-height: 0;&#8221; class=&#8221;mce_SELRES_start&#8221;&amp;gt;\ufeff&amp;lt;\/span&amp;gt;<\/iframe><\/p>\n<p>&nbsp;<\/p>\n<p><span style=\"font-size: 14pt;\"><span class=\"TextRun Highlight SCXW233348545 BCX4\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"none\"><span class=\"NormalTextRun SCXW233348545 BCX4\">The hyperreflexia suggests an upper motor neuron lesion. Next, you check for Hoffmann&#8217;s sign, which if present, would suggest a cervical lesion.<\/span><\/span><\/span><\/p>\n<p style=\"text-align: center;\"><iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/472434101?loop=1\" width=\"320\" height=\"550\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\">&amp;lt;span data-mce-type=&#8221;bookmark&#8221; style=&#8221;display: inline-block; width: 0px; overflow: hidden; line-height: 0;&#8221; class=&#8221;mce_SELRES_start&#8221;&amp;gt;\ufeff&amp;lt;\/span&amp;gt;<\/iframe><\/p>\n<p><span style=\"font-size: 14pt;\"><span class=\"TextRun Highlight SCXW233348545 BCX4\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"none\"><span class=\"NormalTextRun SCXW233348545 BCX4\"><span class=\"TextRun Highlight SCXW222574868 BCX4\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"none\"><span class=\"NormalTextRun SCXW222574868 BCX4\">You have just diagnosed cervical myelopathy. Using only your eyes and a reflex hammer.<\/span><\/span><span class=\"EOP SCXW222574868 BCX4\" data-ccp-props=\"{}\">\u00a0<\/span><\/span><\/span><\/span>[\/vc_column_text][\/vc_column][\/vc_row][vc_row][vc_column][vc_column_text]\n<h1>Patient 4:<\/h1>\n[\/vc_column_text][\/vc_column][\/vc_row][vc_row css=&#8221;.vc_custom_1592017173859{background-color: #dcd9dd !important;}&#8221;][vc_column][vc_column_text]<span style=\"font-size: 14pt;\"><span class=\"TextRun Highlight SCXW131820948 BCX4\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"none\"><span class=\"NormalTextRun SCXW131820948 BCX4\">A middle-aged woman presents with progressive dyspnea. You start with her hands. What do you notice? Does it generate any hypotheses in your mind?<\/span><\/span><span class=\"EOP SCXW131820948 BCX4\" data-ccp-props=\"{}\">\u00a0<\/span><\/span><\/p>\n<p><img decoding=\"async\" loading=\"lazy\" class=\"aligncenter size-medium wp-image-10789\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/IMG_7584-225x300.jpg\" alt=\"\" width=\"225\" height=\"300\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/IMG_7584-225x300.jpg 225w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/IMG_7584-768x1024.jpg 768w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/IMG_7584-1152x1536.jpg 1152w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/IMG_7584-1536x2048.jpg 1536w\" sizes=\"auto, (max-width: 225px) 100vw, 225px\" \/><\/p>\n<p><span style=\"font-size: 14pt;\"><span class=\"TextRun Highlight SCXW43288244 BCX4\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"none\"><span class=\"NormalTextRun SCXW43288244 BCX4\">Could these small erythematous lesions be telangiectasias? Let&#8217;s see if they blanch and refill by pressing on one of them.<\/span><\/span><\/span><\/p>\n<p style=\"text-align: center;\"><iframe loading=\"lazy\" title=\"IMG_7586.MOV\" src=\"https:\/\/player.vimeo.com\/video\/674691946?h=9ee2aea473&amp;badge=0&amp;autopause=0&amp;player_id=0&amp;app_id=58479\" width=\"270\" height=\"480\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><span style=\"display: inline-block; width: 0px; overflow: hidden; line-height: 0;\" data-mce-type=\"bookmark\" class=\"mce_SELRES_start\">\ufeff<\/span><span style=\"display: inline-block; width: 0px; overflow: hidden; line-height: 0;\" data-mce-type=\"bookmark\" class=\"mce_SELRES_start\">\ufeff<\/span><span style=\"display: inline-block; width: 0px; overflow: hidden; line-height: 0;\" data-mce-type=\"bookmark\" class=\"mce_SELRES_start\">\ufeff<\/span><\/iframe><br \/>\n<span style=\"font-size: 14pt;\">Indeed, they do, confirming your suspicion. What condition comes to mind? Perhaps you are thinking about hereditary hemorrhagic telangiectasia (HHT). Can it cause dyspnea? Yes, via pulmonary AVMs. What other condition can present with telangiectasias that may involve the lungs?\u00a0<\/span><\/p>\n<p><span style=\"font-size: 14pt;\" data-ccp-props=\"{}\">\u00a0<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">Your new hypothesis leads you to examine the hands further, discovering that the patient has a hard time completely straightening her fingers. You ask her to make the universal sign of prayer.<\/span><\/p>\n<p><span style=\"font-size: 14pt;\"><span class=\"TextRun Highlight SCXW189683861 BCX4\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"none\"><span class=\"NormalTextRun SCXW189683861 BCX4\"><img decoding=\"async\" loading=\"lazy\" class=\"aligncenter size-medium wp-image-10787\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/IMG_7582-225x300.jpg\" alt=\"\" width=\"225\" height=\"300\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/IMG_7582-225x300.jpg 225w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/IMG_7582-768x1024.jpg 768w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/IMG_7582-1152x1536.jpg 1152w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/IMG_7582-1536x2048.jpg 1536w\" sizes=\"auto, (max-width: 225px) 100vw, 225px\" \/><\/span><\/span><\/span><\/p>\n<p><span style=\"font-size: 14pt;\"><span class=\"TextRun Highlight SCXW189683861 BCX4\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"none\"><span class=\"NormalTextRun SCXW189683861 BCX4\">You search her skin for other signs of the condition that is now at the forefront of your mind. What is this hard, white nodule on her elbow? Does it further advance your hypothesis?<\/span><\/span><span class=\"EOP SCXW189683861 BCX4\" data-ccp-props=\"{}\">\u00a0<\/span><\/span><\/p>\n<p><span style=\"font-size: 14pt;\"><img decoding=\"async\" loading=\"lazy\" class=\"aligncenter size-medium wp-image-11097\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Calcinosis_Cutis_logo-226x300.jpg\" alt=\"\" width=\"226\" height=\"300\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Calcinosis_Cutis_logo-226x300.jpg 226w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Calcinosis_Cutis_logo-773x1024.jpg 773w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Calcinosis_Cutis_logo-768x1018.jpg 768w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Calcinosis_Cutis_logo.jpg 805w\" sizes=\"auto, (max-width: 226px) 100vw, 226px\" \/><\/span><\/p>\n<p><span style=\"font-size: 14pt;\">So what about the dyspnea? How does the condition you have in mind affect the lungs? You look for evidence of pulmonary hypertension on exam. You start with the jugular venous pulse. What finding is present?\u00a0<\/span><\/p>\n<p style=\"text-align: center;\"><iframe loading=\"lazy\" title=\"IMG_7573.MOV\" src=\"https:\/\/player.vimeo.com\/video\/674691121?h=6092ca95ff&amp;badge=0&amp;autopause=0&amp;player_id=0&amp;app_id=58479\" width=\"360\" height=\"640\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p><span style=\"font-size: 14pt;\" data-ccp-props=\"{}\">\u00a0<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">Then you auscult the heart. What finding is present? What is your ultimate diagnosis?<\/span><\/p>\n<p style=\"text-align: center;\"><iframe loading=\"lazy\" title=\"PersistentlySplitS2_4\" src=\"https:\/\/player.vimeo.com\/video\/463362896?h=30047f9c95&amp;badge=0&amp;autopause=0&amp;player_id=0&amp;app_id=58479\" width=\"682\" height=\"310\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p><span style=\"font-size: 14pt;\">This patient has scleroderma with systemic involvement (SSc). Typical cutaneous manifestations include telangiectasias, sclerodactyly (+ Prayer sign), and calcinosis cutis (nodule on her elbow). SSc can cause pulmonary hypertension, leading to Kussmaul&#8217;s sign and loud P2.\u00a0<\/span><\/p>\n<p><span data-ccp-props=\"{}\">\u00a0<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">A standardized test would provide all of these clues on a silver platter. Any machine can synthesize them and make the diagnosis. The clinician must not only synthesize, but gather these clues at the bedside. Your search must be hypothesis-driven or you might miss them.\u00a0<\/span><\/p>\n<p><span style=\"font-size: 14pt;\" data-ccp-props=\"{}\">\u00a0<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">Anticipation is key in medicine. The eyes can&#8217;t see what the mind doesn&#8217;t know. The ears can&#8217;t hear what the mind doesn&#8217;t know.\u00a0<\/span><\/p>\n<p><span style=\"font-size: 14pt;\" data-ccp-props=\"{}\">\u00a0<\/span>[\/vc_column_text][\/vc_column][\/vc_row][vc_row][vc_column][vc_column_text]\n<h1>Patient 5:<\/h1>\n[\/vc_column_text][\/vc_column][\/vc_row][vc_row css=&#8221;.vc_custom_1592017173859{background-color: #dcd9dd !important;}&#8221;][vc_column][vc_column_text]<span style=\"font-size: 14pt;\"><span class=\"TextRun Highlight SCXW261922039 BCX4\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"none\"><span class=\"NormalTextRun ContextualSpellingAndGrammarErrorV2 SCXW261922039 BCX4\">So<\/span><span class=\"NormalTextRun SCXW261922039 BCX4\"> you hear an extra heart sound. Now what? First: Is the extra sound near S1 or S2? Each scenario is associated with a different differential. Listen to this clip. Is the extra sound here near S1 or S2?<\/span><\/span><span class=\"EOP SCXW261922039 BCX4\" data-ccp-props=\"{}\">\u00a0<\/span><\/span><\/p>\n<p style=\"text-align: center;\"><iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/482925513?loop=1\" width=\"640\" height=\"291\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\">&amp;amp;amp;lt;span data-mce-type=&#8221;bookmark&#8221; style=&#8221;display: inline-block; width: 0px; overflow: hidden; line-height: 0;&#8221; class=&#8221;mce_SELRES_start&#8221;&amp;amp;amp;gt;\ufeff&amp;amp;amp;lt;\/span&amp;amp;amp;gt;<\/iframe><\/p>\n<p><span style=\"font-size: 14pt;\">Not sure you hear three sounds? To orient you, listen to normal S1 and S2. There are two sounds here.<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">Back to our patient. So is the extra sound near S1 or near S2? It is near S2. What is the differential?\u00a0\u00a0<\/span><\/p>\n<p><span style=\"font-size: 14pt;\" data-ccp-props=\"{}\">\u00a0<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">DDx: Split S2\u00a0\u00a0<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">S3 gallop\u00a0\u00a0<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">Opening snap\u00a0\u00a0<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">Pericardial knock\u00a0\u00a0<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">Tumor plop\u00a0<\/span><\/p>\n<p>&nbsp;<\/p>\n<p><span style=\"font-size: 14pt;\">Persistently split S2 and S3 gallop are most common. Let&#8217;s start there. How do you distinguish them? Split S2: best heard over BASE, with DIAPHRAGM, closer to S2 S3: best heard over APEX, with BELL, further from S2\u00a0<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">Take a listen to this clip. There is an extra sound near S2. What is it? It is heard over the base of the heart with the diaphragm of the scope (see key in top left of video).\u00a0<\/span><\/p>\n<p><span style=\"font-size: 14pt;\" data-ccp-props=\"{}\">\u00a0<\/span><\/p>\n<p style=\"text-align: center;\"><iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/463361160?loop=1 \" width=\"640\" height=\"291\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\">&amp;lt;span data-mce-type=&#8221;bookmark&#8221; style=&#8221;display: inline-block; width: 0px; overflow: hidden; line-height: 0;&#8221; class=&#8221;mce_SELRES_start&#8221;&amp;gt;\ufeff&amp;lt;\/span&amp;gt;<\/iframe><\/p>\n<p style=\"text-align: center;\"><span class=\"TextRun Highlight SCXW23802564 BCX4\" lang=\"EN-US\" style=\"font-size: 14pt;\" xml:lang=\"EN-US\" data-contrast=\"none\"><span class=\"NormalTextRun SCXW23802564 BCX4\">This is a persistently split S2. (S1 is also split.)<\/span><\/span><\/p>\n<p style=\"text-align: center;\"><span style=\"font-size: 14pt;\"><span class=\"TextRun Highlight SCXW259541561 BCX4\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"none\"><span class=\"NormalTextRun SCXW259541561 BCX4\">What about the <\/span><span class=\"NormalTextRun SpellingErrorV2 SCXW259541561 BCX4\">the<\/span><span class=\"NormalTextRun SCXW259541561 BCX4\"> opening snap? It occurs further from S2 than the split S2, but closer to S2 than the S3 gallop and pericardial knock. It is best heard with the diaphragm and closer to the apex. Take a listen in this patient with severe mitral stenosis:<\/span><\/span><span class=\"EOP SCXW259541561 BCX4\" data-ccp-props=\"{}\">\u00a0<\/span><\/span><\/p>\n<p>&nbsp;<\/p>\n<p style=\"text-align: center;\"><iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/468821675?loop=1 \" width=\"640\" height=\"291\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\">&amp;amp;amp;lt;span data-mce-type=&#8221;bookmark&#8221; style=&#8221;display: inline-block; width: 0px; overflow: hidden; line-height: 0;&#8221; class=&#8221;mce_SELRES_start&#8221;&amp;amp;amp;gt;\ufeff&amp;amp;amp;lt;\/span&amp;amp;amp;gt;<\/iframe><\/p>\n<p><span style=\"font-size: 14pt;\">What about the the pericardial knock? It occurs outside the range for a split S2 and the OS of mitral stenosis, but not as far from S2 as an S3. It is best heard with the diaphragm over the LLSB\/apex. Take a listen in this patient with constrictive pericarditis:\u00a0<\/span><\/p>\n<p style=\"text-align: center;\"><iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/463376439?loop=1\" width=\"640\" height=\"291\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\">&amp;lt;span data-mce-type=&#8221;bookmark&#8221; style=&#8221;display: inline-block; width: 0px; overflow: hidden; line-height: 0;&#8221; class=&#8221;mce_SELRES_start&#8221;&amp;gt;\ufeff&amp;lt;\/span&amp;gt;<\/iframe><\/p>\n<p style=\"text-align: center;\"><span style=\"font-size: 14pt;\"><span class=\"TextRun Highlight SCXW205770345 BCX4\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"none\"><span class=\"NormalTextRun SCXW205770345 BCX4\">So back to our patient. What is the extra sound? Orienting yourself to the cardiac cycle is critical. Is the sound near S1 or near S2? How far from S2 is the sound? Is it high- or low-pitched? Is it best heard over the base or apex?<\/span><\/span><span class=\"EOP SCXW205770345 BCX4\" data-ccp-props=\"{}\">\u00a0<\/span><\/span><\/p>\n<p>&nbsp;<\/p>\n<p><span style=\"font-size: 14pt;\">Our patient has an S3 gallop.\u00a0<\/span><\/p>\n<p><span style=\"font-size: 14pt;\" data-ccp-props=\"{}\">\u00a0<\/span><\/p>\n<p style=\"text-align: center;\"><iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/482928785?loop=1\" width=\"640\" height=\"291\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\">&amp;amp;amp;lt;span data-mce-type=&#8221;bookmark&#8221; style=&#8221;display: inline-block; width: 0px; overflow: hidden; line-height: 0;&#8221; class=&#8221;mce_SELRES_start&#8221;&amp;amp;amp;gt;\ufeff&amp;amp;amp;lt;\/span&amp;amp;amp;gt;<\/iframe><\/p>\n<p><span style=\"font-size: 14pt;\" data-contrast=\"none\">Never forget importance of history and associated findings. The exam is not practiced in a vacuum. Is pt from a country where rheumatic heart disease is prevalent? Does the patient have sharp and deep X\/Y descents indicative of constriction? Other signs of heart failure?<\/span>[\/vc_column_text][\/vc_column][\/vc_row][vc_row][vc_column][vc_column_text]\n<h1>Patient 6:<\/h1>\n[\/vc_column_text][\/vc_column][\/vc_row][vc_row css=&#8221;.vc_custom_1592017173859{background-color: #dcd9dd !important;}&#8221;][vc_column][vc_column_text]<span style=\"font-size: 14pt;\"><span class=\"TextRun Highlight SCXW54208499 BCX4\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"none\"><span class=\"NormalTextRun SCXW54208499 BCX4\">You hear an extra transient heart sound near S1. Now what?<\/span><\/span><span class=\"EOP SCXW54208499 BCX4\" data-ccp-props=\"{}\">\u00a0<\/span><\/span><\/p>\n<p>&nbsp;<\/p>\n<p style=\"text-align: center;\"><iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/652053032?loop=1\" width=\"640\" height=\"291\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><span style=\"display: inline-block; width: 0px; overflow: hidden; line-height: 0;\" data-mce-type=\"bookmark\" class=\"mce_SELRES_start\">\ufeff<\/span><\/iframe><\/p>\n<p><span style=\"font-size: 14pt;\"><span class=\"TextRun Highlight SCXW89603085 BCX4\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"none\"><span class=\"NormalTextRun SCXW89603085 BCX4\">Not sure you hear three sounds? Here is normal S1 and S2 to serve as a control.\u00a0<\/span><\/span><span class=\"EOP SCXW89603085 BCX4\" data-ccp-props=\"{}\">\u00a0<\/span><\/span><\/p>\n<p style=\"text-align: center;\"><iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/479441036?loop=1\" width=\"640\" height=\"291\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\">&amp;amp;amp;amp;amp;lt;span data-mce-type=&#8221;bookmark&#8221; style=&#8221;display: inline-block; width: 0px; overflow: hidden; line-height: 0;&#8221; class=&#8221;mce_SELRES_start&#8221;&amp;amp;amp;amp;amp;gt;\ufeff&amp;amp;amp;amp;amp;lt;\/span&amp;amp;amp;amp;amp;gt;<\/iframe><\/p>\n<p><span style=\"font-size: 14pt;\">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.\u00a0<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">So what&#8217;s the differential for extra transient sounds near S1?\u00a0\u00a0<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">DDx:\u00a0\u00a0<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">Split S1\u00a0\u00a0<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">S4 gallop\u00a0\u00a0<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">Ejection click\u00a0<\/span><\/p>\n<p>&nbsp;<\/p>\n<p><span style=\"font-size: 14pt;\">Split S1 and S4 gallop can be challenging to distinguish because both are best heard over the APEX area. However, the split S1 sounds are closer together than the S1-S4 interval. And the S4 is best heard with the BELL of the scope. Listen to this split S1:\u00a0<\/span><\/p>\n<p style=\"text-align: center;\"><iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/463363539?loop=1\" width=\"640\" height=\"291\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p style=\"text-align: center;\"><span style=\"font-size: 14pt;\">Now take a listen to this S4 gallop:\u00a0<\/span><\/p>\n<p style=\"text-align: center;\"><iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/463375868?loop=1 \" width=\"640\" height=\"291\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\">&amp;lt;span data-mce-type=&#8221;bookmark&#8221; style=&#8221;display: inline-block; width: 0px; overflow: hidden; line-height: 0;&#8221; class=&#8221;mce_SELRES_start&#8221;&amp;gt;\ufeff&amp;lt;\/span&amp;gt;<\/iframe><\/p>\n<p><span style=\"font-size: 14pt;\">Notice that the S1-S4 interval is longer compared to the split S1 above. And while we are listening over the same area of the chest (apex), the bell is being used rather than the diaphragm.\u00a0<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">What about the ejection click? It is perhaps the easiest to distinguish because it is often heard over the BASE of the heart &#8211; very atypical for the split S1 and S4. The click is best appreciated with the diaphragm of the scope as it is higher pitched.\u00a0<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">So back to our patient. What is the extra sound?\u00a0<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">It is heard over the base of the heart with the diaphragm. This is an ejection click. (It was picked up on routine exam and led to the diagnosis of a severely dilated aortic root.)\u00a0\u00a0<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">Remember that the exam is never performed in a vacuum. You will also have the benefit of the history and other findings. Does the patient have longstanding HTN (S4)? Does the patient have a giant a wave with an RV heave suggestive of pulmonary hypertension (click)?\u00a0<\/span><\/p>\n<p><span style=\"font-size: 14pt;\" data-ccp-props=\"{}\">\u00a0<\/span>[\/vc_column_text][\/vc_column][\/vc_row][vc_row][vc_column][vc_column_text]\n<h1>Patient 7:<\/h1>\n[\/vc_column_text][\/vc_column][\/vc_row][vc_row css=&#8221;.vc_custom_1592017173859{background-color: #dcd9dd !important;}&#8221;][vc_column][vc_column_text]<span style=\"font-size: 14pt;\"><span class=\"TextRun Highlight SCXW134549974 BCX4\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"none\"><span class=\"NormalTextRun SCXW134549974 BCX4\">A 50-y\/o man presents with exertional dyspnea. The two main systems responsible for dyspnea are the heart and the lungs.<\/span><\/span> <\/span><\/p>\n<div id='gallery-3' class='gallery galleryid-11020 gallery-columns-3 gallery-size-medium'><figure class='gallery-item'>\n\t\t\t<div class='gallery-icon landscape'>\n\t\t\t\t<a href='https:\/\/up.physicaldiagnosispdx.com\/up\/fixq6qgvkaaua-9\/'><img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"114\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FIxq6QgVkAAuA-9-300x114.jpeg\" class=\"attachment-medium size-medium\" alt=\"\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FIxq6QgVkAAuA-9-300x114.jpeg 300w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FIxq6QgVkAAuA-9-1024x387.jpeg 1024w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FIxq6QgVkAAuA-9-768x291.jpeg 768w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FIxq6QgVkAAuA-9.jpeg 1250w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a>\n\t\t\t<\/div><\/figure>\n\t\t<\/div>\n\n<p><span style=\"font-size: 14pt;\"><span class=\"TextRun Highlight SCXW228792525 BCX4\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"none\"><span class=\"NormalTextRun SCXW228792525 BCX4\">The jugular venous pulse can serve as a pivot point. It can take you toward or away from the heart. <\/span><\/span><\/span><span style=\"font-size: 14pt;\"><span class=\"TextRun Highlight SCXW228792525 BCX4\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"none\"><span class=\"NormalTextRun SCXW228792525 BCX4\">With this in mind, you evaluate the patient&#8217;s neck. What do you notice?<\/span><\/span><span class=\"EOP SCXW228792525 BCX4\" data-ccp-props=\"{}\">\u00a0<\/span><\/span><\/p>\n<p>&nbsp;<\/p>\n<p style=\"text-align: center;\"><iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/472317185?loop=1\" width=\"320\" height=\"550\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p><span style=\"font-size: 14pt;\"><span class=\"TextRun Highlight SCXW116688610 BCX4\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"none\"><span class=\"NormalTextRun SCXW116688610 BCX4\">Not only is the JVP elevated, but it appears to rise with inspiration. This is known as Kussmaul&#8217;s sign.<\/span><\/span><\/span><\/p>\n<p><span style=\"font-size: 14pt;\"><span class=\"TextRun Highlight SCXW245376309 BCX4\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"none\"><span class=\"NormalTextRun SCXW245376309 BCX4\">In the above video, you may have also noticed a mark on the patient&#8217;s skin, just below the &#8220;a wave&#8221; in our logo. Here is the mark up close:<\/span><\/span><\/span><\/p>\n<div id='gallery-4' class='gallery galleryid-11020 gallery-columns-3 gallery-size-medium'><figure class='gallery-item'>\n\t\t\t<div class='gallery-icon portrait'>\n\t\t\t\t<a href='https:\/\/up.physicaldiagnosispdx.com\/up\/hematology-oncology-m\/radiation-tattoos\/radiation_tattoo\/'><img loading=\"lazy\" decoding=\"async\" width=\"225\" height=\"300\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Radiation_Tattoo-225x300.jpg\" class=\"attachment-medium size-medium\" alt=\"\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Radiation_Tattoo-225x300.jpg 225w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Radiation_Tattoo-768x1024.jpg 768w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Radiation_Tattoo-1152x1536.jpg 1152w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Radiation_Tattoo-1536x2048.jpg 1536w\" sizes=\"auto, (max-width: 225px) 100vw, 225px\" \/><\/a>\n\t\t\t<\/div><\/figure>\n\t\t<\/div>\n\n<p>&nbsp;<\/p>\n<p><span style=\"font-size: 14pt;\">What is it?\u00a0<\/span><\/p>\n<p><span data-ccp-props=\"{}\">\u00a0<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">You ask the patient when he had radiation therapy to his chest, and he gives you a surprised look. &#8220;How did you know?&#8221;\u00a0<\/span><\/p>\n<p><span style=\"font-size: 14pt;\" data-ccp-props=\"{}\">\u00a0<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">&#8220;I haven&#8217;t thought about it in 30 years. I had Hodgkin&#8217;s lymphoma when I was 17 years old. They shot radiation at my chest. Why does it matter, doc?&#8221;\u00a0<\/span><\/p>\n<p><span style=\"font-size: 14pt;\" data-ccp-props=\"{}\">\u00a0<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">Next, you listen to the patient&#8217;s heart, anticipating what you might hear. &#8220;The ears can&#8217;t hear what the mind doesn&#8217;t know&#8221;.<\/span><\/p>\n<p>&nbsp;<\/p>\n<p style=\"text-align: center;\"><iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/463364903?loop=1\" width=\"640\" height=\"291\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\">&amp;lt;span data-mce-type=&#8221;bookmark&#8221; style=&#8221;display: inline-block; width: 0px; overflow: hidden; line-height: 0;&#8221; class=&#8221;mce_SELRES_start&#8221;&amp;gt;\ufeff&amp;lt;\/span&amp;gt;<\/iframe><\/p>\n<p>&nbsp;<\/p>\n<p><span style=\"font-size: 14pt;\">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.\u00a0<\/span><\/p>\n<p>&nbsp;<\/p>\n<p style=\"text-align: center;\"><iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/463376439?loop=1\" width=\"640\" height=\"291\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\">&amp;lt;span data-mce-type=&#8221;bookmark&#8221; style=&#8221;display: inline-block; width: 0px; overflow: hidden; line-height: 0;&#8221; class=&#8221;mce_SELRES_start&#8221;&amp;gt;\ufeff&amp;lt;\/span&amp;gt;<\/iframe><\/p>\n<p><span style=\"font-size: 14pt;\"><span class=\"TextRun Highlight SCXW182384021 BCX4\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"none\"><span class=\"NormalTextRun SCXW182384021 BCX4\">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.<\/span><\/span><span class=\"EOP SCXW182384021 BCX4\" data-ccp-props=\"{}\">\u00a0<\/span><\/span>[\/vc_column_text][vc_column_text][\/vc_column_text][\/vc_column][\/vc_row][vc_row][vc_column][vc_column_text]\n<h1>Patient 8:<\/h1>\n[\/vc_column_text][\/vc_column][\/vc_row][vc_row css=&#8221;.vc_custom_1592017173859{background-color: #dcd9dd !important;}&#8221;][vc_column][vc_column_text]<span style=\"font-size: 14pt;\">A man presents to you with the clinical syndrome of heart failure (weight gain, orthopnea, elevated JVP, etc.). BP is 144\/48 mm Hg.<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">This should generate a hypothesis. Yoo you look for other specific physical findings. What do you notice in this video?<\/span><\/p>\n<p style=\"text-align: center;\"><iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/472331617?loop=1\" width=\"320\" height=\"550\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\" data-mce-fragment=\"1\">&amp;amp;lt;span data-mce-type=&#8221;bookmark&#8221; style=&#8221;display: inline-block; width: 0px; overflow: hidden; line-height: 0;&#8221; class=&#8221;mce_SELRES_start&#8221;&amp;amp;gt;\ufeff&amp;amp;lt;\/span&amp;amp;gt;<\/iframe><\/p>\n<p>&nbsp;<\/p>\n<p><span style=\"font-size: 14pt;\">Quincke&#8217;s pulse is consistent with your hypothesis, so you look for more evidence in his neck. And you have found it.<\/span><\/p>\n<p>&nbsp;<\/p>\n<p style=\"text-align: center;\"><iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/472432602?loop=1\" width=\"320\" height=\"550\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\" data-mce-fragment=\"1\">&amp;lt;span data-mce-type=&#8221;bookmark&#8221; style=&#8221;display: inline-block; width: 0px; overflow: hidden; line-height: 0;&#8221; class=&#8221;mce_SELRES_start&#8221;&amp;gt;\ufeff&amp;lt;\/span&amp;gt;<\/iframe><\/p>\n<p><span style=\"font-size: 14pt;\">You then listen to the patient&#8217;s heart in anticipation of hearing a decrescendo diastolic murmur and confirming your suspicions.<\/span><\/p>\n<p style=\"text-align: center;\"><iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/479441040?loop=1\" width=\"640\" height=\"291\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\" data-mce-fragment=\"1\"><\/iframe><\/p>\n<p style=\"text-align: center;\"><span style=\"font-size: 14pt;\">But there is no decrescendo diastolic murmur. Further, his echocardiogram is totally normal. There is no aortic valve pathology. There is no systolic dysfunction.<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">Wide pulse pressure, Quincke&#8217;s pulse, and Corrigan&#8217;s pulse are not specific for aortic regurgitation. They are physical manifestations of a hyperkinetic state from ANY cause.<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">The combination of high-output physiology and HF should generate a new hypothesis. You test your hypothesis with right heart catheterization.<\/span><\/p>\n<p>&nbsp;<\/p>\n<p><span style=\"font-size: 14pt;\"><img decoding=\"async\" loading=\"lazy\" class=\"aligncenter size-medium wp-image-11137\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-16-at-4.21.42-PM-300x257.png\" alt=\"\" width=\"300\" height=\"257\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-16-at-4.21.42-PM-300x257.png 300w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-16-at-4.21.42-PM-1024x879.png 1024w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-16-at-4.21.42-PM-768x659.png 768w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-16-at-4.21.42-PM.png 1198w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/span><\/p>\n<p><span style=\"font-size: 14pt;\">You have diagnosed the patient with high-output heart failure. What&#8217;s causing it?<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">Retrospective history reveals the consumption of 3-4 glasses of wine daily. Hypothesis-driven laboratory investigation is pursued.<\/span><\/p>\n<p><span style=\"font-size: 14pt;\"><br \/>\n<img decoding=\"async\" loading=\"lazy\" class=\"aligncenter size-medium wp-image-11138\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-16-at-4.21.54-PM-300x208.png\" alt=\"\" width=\"300\" height=\"208\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-16-at-4.21.54-PM-300x208.png 300w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-16-at-4.21.54-PM-1024x710.png 1024w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-16-at-4.21.54-PM-768x533.png 768w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-16-at-4.21.54-PM.png 1202w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/span><\/p>\n<p><span style=\"font-size: 14pt;\">You have now diagnosed the patient with high-output heart failure secondary to thiamine deficiency (wet beriberi).<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">Alcohol leads to thiamine deficiency through a variety of mechanisms, including poor diet and decreased absorption of thiamine in the GI tract.<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">Why is the diagnosis of wet beriberi so critical to make? It is curable. Take a look at BP and PP over time with alcohol cessation and thiamine replacement:<\/span><\/p>\n<p><span style=\"font-size: 14pt;\"><img decoding=\"async\" loading=\"lazy\" class=\"aligncenter size-medium wp-image-11136\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKjTd0EVcAE0CT8-300x207.jpeg\" alt=\"\" width=\"300\" height=\"207\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKjTd0EVcAE0CT8-300x207.jpeg 300w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKjTd0EVcAE0CT8-1024x708.jpeg 1024w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKjTd0EVcAE0CT8-768x531.jpeg 768w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKjTd0EVcAE0CT8.jpeg 1109w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/span><\/p>\n<p><span style=\"font-size: 14pt;\">The risk here would have been to diagnose the patient with heart failure with preserved systolic function and then call it a day. &#8220;This is a very common diagnosis, take these diuretics and you&#8217;ll feel better&#8221;.<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">The observation of the physical findings changed everything.<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">This patient was cured without need for diuretics or other long-term meds.<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">The observation of wide pulse pressure and other signs of high-output physiology can provide a pivotal clue to the diagnosis of high-output heart failure, particularly when echo is uninformative.<\/span><\/p>\n[\/vc_column_text][\/vc_column][\/vc_row][vc_row][vc_column][vc_column_text]\n<h1>Patient 9:<\/h1>\n[\/vc_column_text][\/vc_column][\/vc_row][vc_row css=&#8221;.vc_custom_1592017173859{background-color: #dcd9dd !important;}&#8221;][vc_column][vc_column_text]<span style=\"font-size: 14pt;\">A young man comes to your clinic for evaluation of rapid weight gain. He has heard &#8220;diet and exercise&#8221; several times before he sees you.<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">The driver license photo was taken ~9 months prior.<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">You make some observations, leading you to generate a hypothesis.<\/span><\/p>\n<div id='gallery-5' class='gallery galleryid-11020 gallery-columns-3 gallery-size-medium'><figure class='gallery-item'>\n\t\t\t<div class='gallery-icon portrait'>\n\t\t\t\t<a href='https:\/\/up.physicaldiagnosispdx.com\/up\/endocrinology-multimedia\/moon-facies\/endocrinology_cushings-syndrome_moon-facies_img_6733\/'><img loading=\"lazy\" decoding=\"async\" width=\"225\" height=\"300\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Endocrinology_Cushings-Syndrome_Moon-Facies_IMG_6733-scaled-wpp1591075314462-225x300.jpg\" class=\"attachment-medium size-medium\" alt=\"\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Endocrinology_Cushings-Syndrome_Moon-Facies_IMG_6733-scaled-wpp1591075314462-225x300.jpg 225w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Endocrinology_Cushings-Syndrome_Moon-Facies_IMG_6733-scaled-wpp1591075314462.jpg 540w\" sizes=\"auto, (max-width: 225px) 100vw, 225px\" \/><\/a>\n\t\t\t<\/div><\/figure>\n\t\t<\/div>\n\n<p><span style=\"font-size: 14pt;\">Based on your hypothesis, you examine the patient further. And you make several more important observations, increasing the likelihood of your hypothesis.<\/span><\/p>\n<div id='gallery-6' class='gallery galleryid-11020 gallery-columns-3 gallery-size-medium'><figure class='gallery-item'>\n\t\t\t<div class='gallery-icon portrait'>\n\t\t\t\t<a href='https:\/\/up.physicaldiagnosispdx.com\/up\/endocrinology-multimedia\/buffalo-hump\/endocrinology_cushings-syndrome_buffalo-hump_img_6722\/'><img loading=\"lazy\" decoding=\"async\" width=\"225\" height=\"300\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Endocrinology_Cushings-Syndrome_Buffalo-Hump_IMG_6722-scaled-225x300.jpg\" class=\"attachment-medium size-medium\" alt=\"\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Endocrinology_Cushings-Syndrome_Buffalo-Hump_IMG_6722-scaled-225x300.jpg 225w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Endocrinology_Cushings-Syndrome_Buffalo-Hump_IMG_6722-scaled-768x1024.jpg 768w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Endocrinology_Cushings-Syndrome_Buffalo-Hump_IMG_6722-scaled-1152x1536.jpg 1152w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Endocrinology_Cushings-Syndrome_Buffalo-Hump_IMG_6722-scaled-1536x2048.jpg 1536w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Endocrinology_Cushings-Syndrome_Buffalo-Hump_IMG_6722-scaled.jpg 1920w\" sizes=\"auto, (max-width: 225px) 100vw, 225px\" \/><\/a>\n\t\t\t<\/div><\/figure><figure class='gallery-item'>\n\t\t\t<div class='gallery-icon portrait'>\n\t\t\t\t<a href='https:\/\/up.physicaldiagnosispdx.com\/up\/endocrinology-multimedia\/abdominal-striae\/endocrinology_cushings-syndrome_abdominal-striae_img_6715\/'><img loading=\"lazy\" decoding=\"async\" width=\"225\" height=\"300\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Endocrinology_Cushings-Syndrome_Abdominal-Striae_IMG_6715-225x300.jpg\" class=\"attachment-medium size-medium\" alt=\"\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Endocrinology_Cushings-Syndrome_Abdominal-Striae_IMG_6715-225x300.jpg 225w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Endocrinology_Cushings-Syndrome_Abdominal-Striae_IMG_6715-768x1024.jpg 768w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Endocrinology_Cushings-Syndrome_Abdominal-Striae_IMG_6715-1152x1536.jpg 1152w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Endocrinology_Cushings-Syndrome_Abdominal-Striae_IMG_6715-1536x2048.jpg 1536w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Endocrinology_Cushings-Syndrome_Abdominal-Striae_IMG_6715-scaled.jpg 1920w\" sizes=\"auto, (max-width: 225px) 100vw, 225px\" \/><\/a>\n\t\t\t<\/div><\/figure><figure class='gallery-item'>\n\t\t\t<div class='gallery-icon portrait'>\n\t\t\t\t<a href='https:\/\/up.physicaldiagnosispdx.com\/up\/endocrinology-multimedia\/abdominal-striae\/endocrinology_cushings-syndrome_abdominal-striae_img_6718\/'><img loading=\"lazy\" decoding=\"async\" width=\"225\" height=\"300\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Endocrinology_Cushings-Syndrome_Abdominal-Striae_IMG_6718-225x300.jpg\" class=\"attachment-medium size-medium\" alt=\"\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Endocrinology_Cushings-Syndrome_Abdominal-Striae_IMG_6718-225x300.jpg 225w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Endocrinology_Cushings-Syndrome_Abdominal-Striae_IMG_6718-768x1024.jpg 768w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Endocrinology_Cushings-Syndrome_Abdominal-Striae_IMG_6718-1152x1536.jpg 1152w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Endocrinology_Cushings-Syndrome_Abdominal-Striae_IMG_6718-scaled.jpg 1920w\" sizes=\"auto, (max-width: 225px) 100vw, 225px\" \/><\/a>\n\t\t\t<\/div><\/figure>\n\t\t<\/div>\n\n<p><span style=\"font-size: 14pt;\">You remember that skin thickness can be an important sign in this condition, from Lynn Loriaux&#8217;s 2017 @NEJM review.<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">(Examiner&#8217;s hand is shown above, patient&#8217;s below.)<\/span><\/p>\n<div id='gallery-7' class='gallery galleryid-11020 gallery-columns-3 gallery-size-medium'><figure class='gallery-item'>\n\t\t\t<div class='gallery-icon landscape'>\n\t\t\t\t<a href='https:\/\/up.physicaldiagnosispdx.com\/up\/fkdrivnucaeof_8\/'><img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"140\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKDRIVnUcAEOf_8-300x140.jpeg\" class=\"attachment-medium size-medium\" alt=\"\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKDRIVnUcAEOf_8-300x140.jpeg 300w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKDRIVnUcAEOf_8-1024x479.jpeg 1024w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKDRIVnUcAEOf_8-768x359.jpeg 768w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKDRIVnUcAEOf_8.jpeg 1057w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a>\n\t\t\t<\/div><\/figure><figure class='gallery-item'>\n\t\t\t<div class='gallery-icon portrait'>\n\t\t\t\t<a href='https:\/\/up.physicaldiagnosispdx.com\/up\/fkdrrmfveaap183\/'><img loading=\"lazy\" decoding=\"async\" width=\"243\" height=\"300\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKDRRMfVEAAP183-243x300.png\" class=\"attachment-medium size-medium\" alt=\"\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKDRRMfVEAAP183-243x300.png 243w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKDRRMfVEAAP183.png 635w\" sizes=\"auto, (max-width: 243px) 100vw, 243px\" \/><\/a>\n\t\t\t<\/div><\/figure><figure class='gallery-item'>\n\t\t\t<div class='gallery-icon landscape'>\n\t\t\t\t<a href='https:\/\/up.physicaldiagnosispdx.com\/up\/fkdrw8pvcaehqja\/'><img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"274\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKDRW8pVcAEHQJA-300x274.jpeg\" class=\"attachment-medium size-medium\" alt=\"\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKDRW8pVcAEHQJA-300x274.jpeg 300w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKDRW8pVcAEHQJA-768x701.jpeg 768w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKDRW8pVcAEHQJA.jpeg 935w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a>\n\t\t\t<\/div><\/figure>\n\t\t<\/div>\n\n<p><span style=\"font-size: 14pt;\">You now have a clinical syndrome that is consistent with Cushing&#8217;s syndrome.<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">A confirmatory test is your next step.<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">Urine free cortisol (confirmatory test): 7,960 mcg\/24H (!)<\/span><\/p>\n<div id='gallery-8' class='gallery galleryid-11020 gallery-columns-3 gallery-size-medium'><figure class='gallery-item'>\n\t\t\t<div class='gallery-icon landscape'>\n\t\t\t\t<a href='https:\/\/up.physicaldiagnosispdx.com\/up\/fkdajahuyau3squ\/'><img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"169\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKDajAHUYAU3Squ-300x169.jpeg\" class=\"attachment-medium size-medium\" alt=\"\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKDajAHUYAU3Squ-300x169.jpeg 300w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKDajAHUYAU3Squ-768x431.jpeg 768w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKDajAHUYAU3Squ.jpeg 924w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a>\n\t\t\t<\/div><\/figure>\n\t\t<\/div>\n\n<p><span style=\"font-size: 14pt;\">You have now confirmed the diagnosis of Cushing&#8217;s syndrome. The next question is, is it ACTH-dependent or ACTH-independent?<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">A plasma ACTH level is necessary to make this determination.<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">Plasma ACTH level is 496 pg\/mL (normal &lt;50)<\/span><\/p>\n<div id='gallery-9' class='gallery galleryid-11020 gallery-columns-3 gallery-size-medium'><figure class='gallery-item'>\n\t\t\t<div class='gallery-icon landscape'>\n\t\t\t\t<a href='https:\/\/up.physicaldiagnosispdx.com\/up\/fkdavnqucagmraz\/'><img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"174\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKDavNQUcAgMRaz-300x174.jpeg\" class=\"attachment-medium size-medium\" alt=\"\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKDavNQUcAgMRaz-300x174.jpeg 300w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKDavNQUcAgMRaz-768x446.jpeg 768w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKDavNQUcAgMRaz.jpeg 934w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a>\n\t\t\t<\/div><\/figure>\n\t\t<\/div>\n\n<p><span style=\"font-size: 14pt;\">Where is that ACTH coming from? The pituitary gland (ectopic) or elsewhere (ectopic)?<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">To determine this, inferior petrosal sinus sampling is necessary.<\/span><\/p>\n<p><span style=\"font-size: 14pt;\">IPSS shows a ratio &lt;3, confirming an ectopic source of ACTH.<\/span><\/p>\n<div id='gallery-10' class='gallery galleryid-11020 gallery-columns-3 gallery-size-medium'><figure class='gallery-item'>\n\t\t\t<div class='gallery-icon landscape'>\n\t\t\t\t<a href='https:\/\/up.physicaldiagnosispdx.com\/up\/fkdwarkvgaikrv2\/'><img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"116\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKDWaRkVgAIKRv2-300x116.jpeg\" class=\"attachment-medium size-medium\" alt=\"\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKDWaRkVgAIKRv2-300x116.jpeg 300w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKDWaRkVgAIKRv2-1024x396.jpeg 1024w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKDWaRkVgAIKRv2-768x297.jpeg 768w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKDWaRkVgAIKRv2.jpeg 1128w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a>\n\t\t\t<\/div><\/figure><figure class='gallery-item'>\n\t\t\t<div class='gallery-icon landscape'>\n\t\t\t\t<a href='https:\/\/up.physicaldiagnosispdx.com\/up\/fkda6zevkae2hkc\/'><img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"184\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKDa6ZeVkAE2Hkc-300x184.jpeg\" class=\"attachment-medium size-medium\" alt=\"\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKDa6ZeVkAE2Hkc-300x184.jpeg 300w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKDa6ZeVkAE2Hkc-768x472.jpeg 768w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKDa6ZeVkAE2Hkc.jpeg 909w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a>\n\t\t\t<\/div><\/figure>\n\t\t<\/div>\n\n<p><span style=\"font-size: 14pt;\">Chest imaging ultimately reveals the presence of a bronchial carcinoid tumor.<\/span><\/p>\n<div id='gallery-11' class='gallery galleryid-11020 gallery-columns-3 gallery-size-medium'><figure class='gallery-item'>\n\t\t\t<div class='gallery-icon landscape'>\n\t\t\t\t<a href='https:\/\/up.physicaldiagnosispdx.com\/up\/fkdbjv-vcaimbne\/'><img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"179\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKDbJV-VcAImbnE-300x179.jpeg\" class=\"attachment-medium size-medium\" alt=\"\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKDbJV-VcAImbnE-300x179.jpeg 300w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKDbJV-VcAImbnE-768x459.jpeg 768w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FKDbJV-VcAImbnE.jpeg 907w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a>\n\t\t\t<\/div><\/figure>\n\t\t<\/div>\n\n<p><span style=\"font-size: 14pt;\">You have diagnosed ACTH-dependent Cushing&#8217;s syndrome from an ectopic source using only your eyes and hypothesis-driven laboratory and imaging tests.<\/span><\/p>\n[\/vc_column_text][\/vc_column][\/vc_row][vc_row][vc_column][vc_column_text]\n<h1>Patient 10:<\/h1>\n[\/vc_column_text][\/vc_column][\/vc_row][vc_row css=&#8221;.vc_custom_1592017173859{background-color: #dcd9dd !important;}&#8221;][vc_column][vc_column_text]<span style=\"font-size: 14pt;\">You are rotating on the Procedure Service and your team is asked to perform a routine &#8220;therapeutic&#8221; 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.<\/span><\/p>\n<div id='gallery-12' class='gallery galleryid-11020 gallery-columns-3 gallery-size-medium'><figure class='gallery-item'>\n\t\t\t<div class='gallery-icon portrait'>\n\t\t\t\t<a href='https:\/\/up.physicaldiagnosispdx.com\/up\/screen-shot-2022-02-17-at-2-00-57-pm\/'><img loading=\"lazy\" decoding=\"async\" width=\"247\" height=\"300\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-17-at-2.00.57-PM-247x300.png\" class=\"attachment-medium size-medium\" alt=\"\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-17-at-2.00.57-PM-247x300.png 247w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-17-at-2.00.57-PM-843x1024.png 843w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-17-at-2.00.57-PM-768x932.png 768w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-17-at-2.00.57-PM-1265x1536.png 1265w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-17-at-2.00.57-PM.png 1458w\" sizes=\"auto, (max-width: 247px) 100vw, 247px\" \/><\/a>\n\t\t\t<\/div><\/figure><figure class='gallery-item'>\n\t\t\t<div class='gallery-icon portrait'>\n\t\t\t\t<a href='https:\/\/up.physicaldiagnosispdx.com\/up\/screen-shot-2022-02-17-at-2-00-46-pm\/'><img loading=\"lazy\" decoding=\"async\" width=\"175\" height=\"300\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-17-at-2.00.46-PM-175x300.png\" class=\"attachment-medium size-medium\" alt=\"\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-17-at-2.00.46-PM-175x300.png 175w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-17-at-2.00.46-PM-599x1024.png 599w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-17-at-2.00.46-PM-768x1314.png 768w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-17-at-2.00.46-PM-898x1536.png 898w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-17-at-2.00.46-PM.png 1084w\" sizes=\"auto, (max-width: 175px) 100vw, 175px\" \/><\/a>\n\t\t\t<\/div><\/figure>\n\t\t<\/div>\n\n<p><span style=\"font-size: 14pt;\">A &#8220;diagnostic&#8221; paracentesis wasn&#8217;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.<\/span><\/p>\n<div id='gallery-13' class='gallery galleryid-11020 gallery-columns-3 gallery-size-medium'><figure class='gallery-item'>\n\t\t\t<div class='gallery-icon landscape'>\n\t\t\t\t<a href='https:\/\/up.physicaldiagnosispdx.com\/up\/screen-shot-2022-02-17-at-2-01-09-pm\/'><img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"131\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-17-at-2.01.09-PM-300x131.png\" class=\"attachment-medium size-medium\" alt=\"\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-17-at-2.01.09-PM-300x131.png 300w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-17-at-2.01.09-PM-1024x447.png 1024w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-17-at-2.01.09-PM-768x335.png 768w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-17-at-2.01.09-PM-1536x670.png 1536w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-17-at-2.01.09-PM-2048x893.png 2048w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a>\n\t\t\t<\/div><\/figure>\n\t\t<\/div>\n\n<p>&nbsp;<\/p>\n<p><span style=\"font-size: 14pt;\">Serum albumin is 3.1 g\/dL and ascitic fluid album is 0.8 g\/dL, yielding a serum-ascites albumin gradient (SAAG) of 2.3 (&gt;1.1), which is consistent with a portal hypertensive process.<\/span><\/p>\n<p>&nbsp;<\/p>\n<div id='gallery-14' class='gallery galleryid-11020 gallery-columns-3 gallery-size-medium'><figure class='gallery-item'>\n\t\t\t<div class='gallery-icon landscape'>\n\t\t\t\t<a href='https:\/\/up.physicaldiagnosispdx.com\/up\/flrabgwveao4ndj\/'><img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"126\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FLrabGWVEAo4nDJ-300x126.jpeg\" class=\"attachment-medium size-medium\" alt=\"\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FLrabGWVEAo4nDJ-300x126.jpeg 300w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FLrabGWVEAo4nDJ-1024x429.jpeg 1024w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FLrabGWVEAo4nDJ-768x322.jpeg 768w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FLrabGWVEAo4nDJ.jpeg 1148w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a>\n\t\t\t<\/div><\/figure>\n\t\t<\/div>\n\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p><span style=\"font-size: 14pt;\">Next you wonder if the cause of portal HTN is prehepatic, hepatic, or posthepatic. For this you return to the cornerstone of diagnostic medicine, the history and physical examination. You recall the hypothesis generated by the dilated forehead veins and you evaluate the JVP.<\/span><\/p>\n<p style=\"text-align: center;\"><iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/497755356?loop=1\" width=\"320\" height=\"550\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p><span style=\"font-size: 14pt;\">The patient is upright in the video. What do you think right atrial pressure is? High? Low? Normal? It is markedly elevated. Pointing you in the direction of posthepatic causes of portal hypertension.<\/span><\/p>\n<p>&nbsp;<\/p>\n<div id='gallery-15' class='gallery galleryid-11020 gallery-columns-3 gallery-size-medium'><figure class='gallery-item'>\n\t\t\t<div class='gallery-icon landscape'>\n\t\t\t\t<a href='https:\/\/up.physicaldiagnosispdx.com\/up\/case-presentations\/screen-shot-2022-02-17-at-2-01-21-pm\/'><img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"134\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-17-at-2.01.21-PM-300x134.png\" class=\"attachment-medium size-medium\" alt=\"\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-17-at-2.01.21-PM-300x134.png 300w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-17-at-2.01.21-PM-1024x456.png 1024w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-17-at-2.01.21-PM-768x342.png 768w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-17-at-2.01.21-PM-1536x684.png 1536w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-17-at-2.01.21-PM-2048x912.png 2048w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a>\n\t\t\t<\/div><\/figure>\n\t\t<\/div>\n\n<p>&nbsp;<\/p>\n<div class=\"css-1dbjc4n\">\n<div class=\"css-1dbjc4n r-1s2bzr4\">\n<div id=\"id__1y93wz5uogc\" class=\"css-901oao r-1fmj7o5 r-37j5jr r-1blvdjr r-16dba41 r-vrz42v r-bcqeeo r-bnwqim r-qvutc0\" dir=\"auto\" lang=\"en\"><span class=\"css-901oao css-16my406 r-poiln3 r-bcqeeo r-qvutc0\" style=\"font-size: 14pt;\">An echocardiogram is performed, demonstrating severe systolic dysfunction.<\/span><\/div>\n<div dir=\"auto\" lang=\"en\"><\/div>\n<\/div>\n<\/div>\n<div dir=\"auto\" lang=\"en\"><\/div>\n<div dir=\"auto\" lang=\"en\"><\/div>\n<div dir=\"auto\" lang=\"en\">\n<div id='gallery-16' class='gallery galleryid-11020 gallery-columns-3 gallery-size-medium'><figure class='gallery-item'>\n\t\t\t<div class='gallery-icon landscape'>\n\t\t\t\t<a href='https:\/\/up.physicaldiagnosispdx.com\/up\/screen-shot-2022-02-17-at-2-01-33-pm\/'><img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"134\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-17-at-2.01.33-PM-300x134.png\" class=\"attachment-medium size-medium\" alt=\"\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-17-at-2.01.33-PM-300x134.png 300w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-17-at-2.01.33-PM-1024x459.png 1024w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-17-at-2.01.33-PM-768x344.png 768w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/Screen-Shot-2022-02-17-at-2.01.33-PM.png 1178w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a>\n\t\t\t<\/div><\/figure>\n\t\t<\/div>\n\n<\/div>\n<div dir=\"auto\" lang=\"en\"><\/div>\n<div class=\"css-1dbjc4n\">\n<div id=\"id__4bfyp2o1agd\" class=\"css-1dbjc4n\" aria-labelledby=\"id__9blg0hdh3s id__ed2942xbodt\">\n<div class=\"css-1dbjc4n r-1s2bzr4\">\n<div class=\"css-1dbjc4n r-1kqtdi0 r-1867qdf r-1phboty r-rs99b7 r-1ny4l3l r-1udh08x r-o7ynqc r-6416eg\">\n<div class=\"css-1dbjc4n\">\n<div class=\"css-1dbjc4n\">\n<div class=\"css-1dbjc4n r-1adg3ll r-1udh08x\">\n<div class=\"css-1dbjc4n\">\n<div class=\"css-1dbjc4n r-1s2bzr4\">\n<div dir=\"auto\" lang=\"en\"><\/div>\n<div id=\"id__ij36pxdxa5b\" class=\"css-901oao r-1fmj7o5 r-37j5jr r-1blvdjr r-16dba41 r-vrz42v r-bcqeeo r-bnwqim r-qvutc0\" dir=\"auto\" lang=\"en\"><span class=\"css-901oao css-16my406 r-poiln3 r-bcqeeo r-qvutc0\" style=\"font-size: 14pt;\">You diagnose the patient with HF with reduced systolic function, likely caused by chemotherapeutic agents. While cirrhosis and malignancy are common causes of ascites, other etiologies should always be considered. Heart failure is the cause of ascites in this case.<\/span><\/div>\n<div dir=\"auto\" lang=\"en\"><\/div>\n<div dir=\"auto\" lang=\"en\"><\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<div dir=\"auto\" lang=\"en\"><\/div>\n<div dir=\"auto\" lang=\"en\">\n<div id='gallery-17' class='gallery galleryid-11020 gallery-columns-3 gallery-size-medium'><figure class='gallery-item'>\n\t\t\t<div class='gallery-icon landscape'>\n\t\t\t\t<a href='https:\/\/up.physicaldiagnosispdx.com\/up\/case-presentations\/flrg0pguuaqx9me\/'><img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"126\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FLrg0PgUUAQX9me-300x126.jpeg\" class=\"attachment-medium size-medium\" alt=\"\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FLrg0PgUUAQX9me-300x126.jpeg 300w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FLrg0PgUUAQX9me-1024x429.jpeg 1024w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FLrg0PgUUAQX9me-768x322.jpeg 768w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/FLrg0PgUUAQX9me.jpeg 1135w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a>\n\t\t\t<\/div><\/figure>\n\t\t<\/div>\n\n<\/div>\n<div dir=\"auto\" lang=\"en\"><\/div>\n<div dir=\"auto\" lang=\"en\"><\/div>\n<div dir=\"auto\" lang=\"en\"><\/div>\n<div class=\"css-1dbjc4n\">\n<div id=\"id__4bfyp2o1agd\" class=\"css-1dbjc4n\" aria-labelledby=\"id__9blg0hdh3s id__ed2942xbodt\">\n<div class=\"css-1dbjc4n r-1s2bzr4\">\n<div class=\"css-1dbjc4n r-1kqtdi0 r-1867qdf r-1phboty r-rs99b7 r-1ny4l3l r-1udh08x r-o7ynqc r-6416eg\">\n<div class=\"css-1dbjc4n\">\n<div class=\"css-1dbjc4n\">\n<div class=\"css-1dbjc4n r-1adg3ll r-1udh08x\">\n<div class=\"css-1dbjc4n\">\n<div id=\"id__ocjc46q6bwq\" class=\"css-1dbjc4n\" aria-labelledby=\"id__pcmhydiopzr id__4ptn17irk5a\">\n<div class=\"css-1dbjc4n r-1s2bzr4\">\n<div class=\"css-1dbjc4n r-1kqtdi0 r-1867qdf r-1phboty r-rs99b7 r-1ny4l3l r-1udh08x r-o7ynqc r-6416eg\">\n<div class=\"css-1dbjc4n\">\n<div class=\"css-1dbjc4n\">\n<div class=\"css-1dbjc4n r-1adg3ll r-1udh08x\"><\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n[\/vc_column_text][\/vc_column][\/vc_row]\n<\/div>","protected":false},"excerpt":{"rendered":"<p>[vc_row css=&#8221;.vc_custom_1592017154846{background-color: #fff9f9 !important;}&#8221;][vc_column][vc_column_text] Here you will find cases in which physical examination played a key role in making the diagnosis. Try to work through the cases one step at a time and see if you arrive at the correct diagnosis. &nbsp; [\/vc_column_text][\/vc_column][\/vc_row][vc_row][vc_column][vc_column_text][vc_row][vc_column width=&#8221;1\/1&#8243;][vc_column_text] Patient 1: [\/vc_column_text][\/vc_column][\/vc_row][vc_row css=&#8221;.vc_custom_1592017173859{background-color: #dcd9dd !important;}&#8221;][vc_column][vc_column_text]<\/p>\n","protected":false},"author":9,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"open","ping_status":"closed","template":"","meta":{"nf_dc_page":"","_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"_lmt_disableupdate":"no","_lmt_disable":"","footnotes":""},"class_list":["post-11020","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-json\/wp\/v2\/pages\/11020","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-json\/wp\/v2\/users\/9"}],"replies":[{"embeddable":true,"href":"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-json\/wp\/v2\/comments?post=11020"}],"version-history":[{"count":60,"href":"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-json\/wp\/v2\/pages\/11020\/revisions"}],"predecessor-version":[{"id":11175,"href":"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-json\/wp\/v2\/pages\/11020\/revisions\/11175"}],"wp:attachment":[{"href":"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-json\/wp\/v2\/media?parent=11020"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}