Quincke's Pulse in a patient with a normal echocardiogram (non-valvular)

A 70 y/o man presents with new exertional dyspnea, orthopnea/PND, wide pulse pressure (~100 mm Hg), and elevated JVP. A physical finding is identified (video). Echo: preserved systolic function, no valvular disease. Thoughts? What would you do next?

Incredible discussion. Like many here I questioned the echo. Then realized Quincke's pulse = high-output state (not always AR). Sent for RHC to confirm high-output HF. Sure enough, CO was 12.5 L/min (CI 4.8 L/min/m2). Workup for cause underway. 

Physical exam was pivotal in this case. Without it, most of us would have concluded that this was "just another case of diastolic heart failure" and stopped there. Without seeing Quincke's pulse, there is no question that I would have unknowingly marched down the wrong path.

At this point thiamine deficiency (beriberi) and AV shunt are highest on my differential. Patient drinks ~2 glasses of wine/day. EtOH causes thiamine deficiency via several mechanisms, so even if patients consume a normal diet and don't appear malnourished, it is still possible.

Dr. André Mansoor @AndreMansoor - Author of Frameworks for Internal Medicine https://amzn.to/2LmUODZ

#Quinckes #Quinkes #Pulse #AorticRegurgitation #Diagnosis #PhysicalExam #Fingernails #Nailbed #Cardiology
Contributed by

Dr. Gerald Diaz
Board Certified Internal Medicine Hospitalist, GrepMed Editor in Chief 🇵🇭 🇺🇸 - Sign up for an account to like, bookmark and upload images to contribute to our community platform. Follow us on IG:  https://www.instagram.com/grepmed/ | Twitter: https://twitter.com/grepmeded/

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