The Cardiovascular Exam - Pulsus Paradoxus & Special Maneuvers (Strong Exam)

Discussion of the physiology of special cardiovascular exam maneuvers, along with demonstrations, and review of the evidence from the medical literature.
0:00 Introduction
0:41 Orthostatic hypotension
4:35 Signs of hypovolemia (e.g. capillary refill, passive leg raise)
7:57 Signs of heart failure (e.g. proportional pulse pressure, abdominojugular reflux)
10:16 Cardiac tamponade and pulsus paradoxus
References:
McGee S. Evidence Based Physical Diagnosis. 5th Ed. Elsevier; 2021.
Juraschek SP, et al. Association of History of Dizziness and Long-term Adverse Outcomes With Early vs Later Orthostatic Hypotension Assessment Times in Middle-aged Adults. JAMA Intern Med. 2017; 177:1316-1323.
McGee S, Abernethy WB, Simel DL. The Rational Clinical Examination. Is This Patient Hypovolemic? JAMA. 1999; 281:1022-1029.
Schriger DL, et al. Defining Normal Capillary Refill: Variation With Age, Sex, and Temperature. Ann Emerg Med. 1988; 17: 932-935.
Monnet X, Marik P, Teboul, JL. Passive Leg Raising For Predicting Fluid Responsiveness: A Systematic Review and Meta-Analysis. Intensive Care Med. 2016; 42: 1935-1947.
Mesquida J, Gruartmoner G, Ferrer R. Passive Leg Raising For Assessment of Volume Responsiveness: A Review. Curr Opin Crit Care. 2017; 23:237-243.
Sochowski RA, Dubbin JD, Naqvi SZ. Clinical and Hemodynamic Assessment of the Hepatojugular Reflux. Am J Cardiol. 1990; 66:1002-1006.
Butman SM, et al. Bedside cardiovascular examination in patients with severe chronic heart failure: importance of rest or inducible jugular venous distension. 1993; 22:968-974.
Sternbach G. Claude Beck: Cardiac Compression Triads. Journal Emerg Med 1988; 6: 417-419.
Roy CI, et al. Does This Patient With a Pericardial Effusion Have Cardiac Tamponade? JAMA. 2007; 297:1810-1818. [A figure in this paper was the inspiration for the animation starting at @13:05]

Пікірлер: 35

  • @mr.siddharthtyagi
    @mr.siddharthtyagi4 ай бұрын

    I've been watching all previous videos of this series and you had me worried it had stopped! Thanks for continuing and i hope to see each and every aspect of history and examination being covered👍

  • @StrongMed

    @StrongMed

    4 ай бұрын

    Many more are coming. Sorry for worrying you! ;)

  • @zaighamhashir7445

    @zaighamhashir7445

    4 ай бұрын

    Same feelings here

  • @fjs1111

    @fjs1111

    Ай бұрын

    @@StrongMed Yes, thank you Dr. Strong

  • @tuboo_9158
    @tuboo_91584 ай бұрын

    Been watching your videos since day 1 of med school, you have no idea how much on an impact you’ve had on my learning, much appreciation from a budding Canadian internist 😁

  • @MuhammadHassan-px1hw
    @MuhammadHassan-px1hw23 күн бұрын

    From a humble distant student : Dr strong please🙏🏻 🙏🏻 just continue with this 🌾🌾

  • @StrongMed

    @StrongMed

    23 күн бұрын

    As you might imagine, videos in this series require a lot more time than most others on the channel, so I can only record and edit them when my teaching and clinical duties are both low. But don't worry, more are coming this summer!

  • @parkerjk11
    @parkerjk114 ай бұрын

    I think Bates may need an EBM update! Amazing content as always, thank you!

  • @StrongMed

    @StrongMed

    4 ай бұрын

    My dissatisfaction with Bates as a primary reference for my students was one of the main motivations for this series!

  • @gabriellefortin8926
    @gabriellefortin89263 ай бұрын

    Amazing! Clearest explanation of pulsus paradoxus ever! Happy to contribute monthly to Patreon!😊

  • @peev2
    @peev24 ай бұрын

    Always happy when I see a new video from you.

  • @daliaal-ansi5630
    @daliaal-ansi56304 ай бұрын

    I've been looking for this content! Thank you!

  • @jakeesposito-leftwich9152
    @jakeesposito-leftwich91523 ай бұрын

    Brilliant explanation, TYVM!

  • @sunving
    @sunving4 ай бұрын

    oh wonderful lecture , so good .

  • @literalantifaterrorist4673
    @literalantifaterrorist46734 ай бұрын

    Really love this series, we have far more limited diagnostic tools as paramedics so physical exams are king.

  • @Argendoom244
    @Argendoom2444 ай бұрын

    Finally! Thank you so much!

  • @Kalemalex
    @Kalemalex3 ай бұрын

    Thank you professor

  • @alirezazakaie1106
    @alirezazakaie11064 ай бұрын

    Eventually it published...Thank you

  • @damiensegers3555
    @damiensegers35554 ай бұрын

    looking forward to your neurological examination

  • @StrongMed

    @StrongMed

    4 ай бұрын

    It's coming, but will be a while. I didn't have a chance to film the neuro exam before our simulation center (where these are filmed) readopted a mandatory mask policy. Hopefully it gets dropped by late spring for a summer release.

  • @panicbuyflax3461
    @panicbuyflax34614 ай бұрын

    Also I forgot to ask (apologies I know you’re busy). Could you do a video on Testosterone Replacement Therapy? My Uncle’s an endocrinologist specialized in hormone treatment and I think it would be really interesting! Merely a request

  • @StrongMed

    @StrongMed

    4 ай бұрын

    Thank you for the suggestion. I'll add it to the list of topics suggested by viewers, but unfortunately that list is very long, so I can't make a prediction as to when I'll be able to do it.

  • @parkerjk11
    @parkerjk114 ай бұрын

    With the growing availability and affordability of portable ultrasound units, do you think IVC collapsibility is a practical and accurate measure of intravascular volume and hypovolemia?

  • @StrongMed

    @StrongMed

    4 ай бұрын

    Yes, I definitely think this is a helpful finding - particularly to distinguish volume responsiveness vs. diuretic responsiveness. As I had commented to another viewer, I had decided when planning out this series that I would not include discussion and demonstration of POCUS for this first iteration, but hope to add it down the road. In the meantime, the Stanford 25 KZread channel has some great videos that cover it.

  • @hafizalkaf
    @hafizalkaf4 ай бұрын

    What about ultraound finding such as IVC diameter and Collapsibility for hipovolemia and B lines for lung oedema

  • @StrongMed

    @StrongMed

    4 ай бұрын

    This is great question! Those are all very helpful findings for assessing volume status. I made the decision when planning this series to not include POCUS findings in this its iteration because it's not yet commonplace around the world - though I do hope to circle back and later create separate videos in the same style describing POCUS for CV, pulm, and the abdominal exams. In the meantime, my colleagues with the Stanford 25 group have created a great series of POCUS videos covering those findings and many more: kzread.info/head/PLE6bR3gooUQs5rt_YQmruApuLcV3V7O3a

  • @panicbuyflax3461
    @panicbuyflax34614 ай бұрын

    Eric, just curious. Why does capillary refill time vary between men and women? Cheers -Bradley

  • @StrongMed

    @StrongMed

    4 ай бұрын

    I don't think anyone knows, and as I hope I conveyed in the video, it's just a single study that found this (which is also the only study that's ever looked at the question of whether there are age and sex differences in the normal range of cap refill time). The authors did not speculate as to the potential explanation. Interestingly, the *median* capillary refill time did not vary dramatically between men and women, but rather just the *mean* and thus the calculated upper limit of normal. In other words, most men and women were about the same, but a relatively small number of women were outliers who skewed the mean. (i.e. women had a much larger standard deviation). The relevant study: pubmed.ncbi.nlm.nih.gov/3415066/

  • @arjumandiqbal1787
    @arjumandiqbal17874 ай бұрын

    hello !! when will complete cardiovascular exam be out???

  • @StrongMed

    @StrongMed

    4 ай бұрын

    Working on it now, but it's a monster! (i.e. about an hour in length...)

  • @arjumandiqbal1787

    @arjumandiqbal1787

    4 ай бұрын

    @@StrongMed you're my biggest inspiration!! I'm at the top of my class rn because of it and have my exam in about a week, so that's why I'm waiting for this specific exam , would it be possible that it's out in a week?

  • @StrongMed

    @StrongMed

    4 ай бұрын

    ​@@arjumandiqbal1787 Thanks for the kind words! Regarding the core CV exam video, my goal was to release it on Sunday, but I honestly don't think it will be ready by then. It may end up being my longest and most complicated video to date.

  • @TheJeenyus24
    @TheJeenyus244 ай бұрын

    I would argue that cardiac tamponade is a clinical diagnosis. An echo should not change the diagnosis unless the clinical features are somewhat borderline, then an echo can help.

  • @StrongMed

    @StrongMed

    4 ай бұрын

    I don't disagree with you, but if there is a cardiologist out there who will perform an emergent pericardiocentesis on a patient with "clinical tamponade" but without evidence of tamponade on echo, I haven't met them.

  • @alirezazakaie1106
    @alirezazakaie11063 ай бұрын

    Still waiting...🤕