{"id":11092,"date":"2022-02-07T19:36:15","date_gmt":"2022-02-08T03:36:15","guid":{"rendered":"https:\/\/up.physicaldiagnosispdx.com\/up\/?page_id=11092"},"modified":"2022-02-07T19:42:20","modified_gmt":"2022-02-08T03:42:20","slug":"11092-2","status":"publish","type":"page","link":"https:\/\/up.physicaldiagnosispdx.com\/up\/11092-2\/","title":{"rendered":""},"content":{"rendered":"<div class=\"wpb-content-wrapper\">[vc_row css=&#8221;.vc_custom_1592017154846{background-color: #fff9f9 !important;}&#8221;][vc_column][vc_column_text]<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]\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]<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]\n<\/div>","protected":false},"excerpt":{"rendered":"<p>[vc_row css=&#8221;.vc_custom_1592017154846{background-color: #fff9f9 !important;}&#8221;][vc_column][vc_column_text][\/vc_column_text][\/vc_column][\/vc_row][vc_row][vc_column][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]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?\u00a0 Could these small erythematous lesions be telangiectasias? Let&#8217;s see if they blanch and refill by pressing on<\/p>\n","protected":false},"author":9,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"page-templates\/page_PDXPDX-full-width.php","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-11092","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-json\/wp\/v2\/pages\/11092","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=11092"}],"version-history":[{"count":6,"href":"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-json\/wp\/v2\/pages\/11092\/revisions"}],"predecessor-version":[{"id":11103,"href":"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-json\/wp\/v2\/pages\/11092\/revisions\/11103"}],"wp:attachment":[{"href":"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-json\/wp\/v2\/media?parent=11092"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}