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Part 3
Some VERY LUCKY male patients (or better lucky bastards! xD) while they're stethed, examined or having their blood pressure taken by female doctors and nurses during sports medicine examinations, stress tests and home exams
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Q. What does an atrial septal defect (ASD) sound like on auscultation?
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A. Unlike ventricular septal defects (VSDs), an inter-atrial defect causes no murmur itself. However, a number of adventitious sounds may be associated with it.
- wide and fixed S2, due to the larger-than-normal volume of blood that is sent through the right-sided circulation, causing a later-than-normal closing of the pulmonary valve (the second sound in S2)
- a crescendo-decrescendo early systolic ejection murmur from the pulmonic valve heard best at the right upper sternal border (RUSB)
- a rumbling mid-diastolic murmur from blood rushing through the tricuspid valve heard best at the left lower sternal border (LLSB)
Pro-Tip: S2 is only wide and fixed when pulmonary resistance is low; if the defect remains open long enough, the extra blood flow will increase pulmonary vascular resistance, decreasing blood flow into the lungs and across the ASD, eventually resulting in Eisenmenger Syndrome.
Example courtesy of Thinklabs
Earlier in February of this year, before COVID-19's onslaught in London, UK, I was covering service on a respiratory ward when a young medical student made herself known to the physician's office. "Could I borrow your stethoscope? I'm here to practice my respiratory examinations."
“And yet here, on a respiratory ward, where listening to chests is a focal feature of every round, I was met with a student doctor who did not think to bring one.”
New on in-House, UK clinical fellow Grace Hatton, MPharm, MBChB, DTM&H, wonders whether the #stethoscope has become obsolete.
https://in-housestaff.org/has-the-stethoscope-had-its-day-1860
Q. How can you differentiate between transient synovitis and septic arthritis of the hip in a child?
A. Use the Kocher Criteria to differentiate between intermediate-risk children with non-traumatic hip pain. Non-weight bearing WBC>12 Temp>38.5C ESR>40
"The Kocher criteria remain a helpful set of clinical risk factors differentiating SA and TS in pediatric patients presenting with hip pain. The criteria include the increasing diagnostic probability in favor of the former, yielding a 99.6% probability favoring SA as a diagnosis when all four criteria are met: WBC > 12,000 cells per microliter of serum Inability or refusal to bear weight Febrile (> 101.3 degrees Fahrenheit or 38.5 degrees celsius) ESR > 40 mm/hr
When none of the above risk factors are present upon presentation, the probability of the patient having SA of the hip drops below 0.2%. A subsequent study incorporated CRP measurements into the clinical workup. Caird et al. performed a Level I study that concluded that a temperature above 38.5 was the best predictor of septic arthritis followed in decreasing order by CRP (>1mg/dL), ESR, refusal to bear weight, and serum WBC count.
Another physical exam finding for cirrhosis is palmar erythema. Put one hand over your head and drop the other by your side. Wait several heartbeats. Now compare them: the dependent hand demonstrates palmar erythema.
The presence of palmar erythema increases the likelihood of cirrhosis 10-20%.The absence of palmar erythema decreases the likelihood of cirrhosis ~10%.
Credit: Dr. Robert Trowbridge, Jr., ACP Internist (2022)
Image: Cirrhosiscare.ca
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This week's topic is CHARGE Syndrome, which stands for C_____, Heart defects, Atresia of the choanae, Restricted growth/development, Genitourinary abnormalities, and Ear abnormalities.
Choanal atresia is obstruction of the nasal passage(s). Infants with bilateral choanal atresia plus other birth defects tend to have poorer outcomes than those with unilateral obstruction of a choana.
Image: A: Unilateral choanal atresia; B: Bilateral choanal atresia. Contributed by Claudio Andaloro, MD. From: StatPearls Publishing LLC.
Physical exam features of myasthenia gravis often include ptosis and diplopia. Pro-Tip: Because repeated firing of the neuron is required to exhaust the synaptic supply of acetylcholine (ACh), you may need to ask the person to look up for 2 minutes in order to fatigue the palpebral muscles.
Image: thepajo.org
Q. How would you describe the murmur most typically heard in Noonan Syndrome? . . . . . A. Because pulmonary stenosis is the most common defect, you would expect a systolic ejection murmur heard best at the left upper sternal border (2nd intercostal space) that can split S2.
