Ryan O'Keefe

Learn more clinical pearls from the Point of Care Medicine Substack!

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Source: CPS - December 11, 2025 VMR with Rabih & Sarah B - sudden onset left sided neurological deficits

Daily Pearl:

Septic emboli are a strong contraindication to thrombolysis (tPA) for ischemic stroke due to the high risk of hemorrhagic transformation from underlying vasculitis or a pre-existing mycotic aneurysm.

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A low-pitched, diastolic “rumbling” murmur (mitral stenosis) or a holosystolic murmur (mitral regurgitation) may be heard.

A loud S1 and an opening snap can also be present in mitral stenosis.

Source: CPS - December 9, 2025 VMR with Ravi & Kirtan - SOB for 3 days and LE edema for 3 months

Daily Pearl(s):

Rheumatic Mitral Stenosis

The pathognomonic finding for rheumatic mitral stenosis is the “hockey stick” appearance of the anterior mitral leaflet during diastole, caused by fusion at the leaflet tips while the base remains mobile.

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Source: CPS - December 5, 2025 VMR with Rabih & Academy - 1: Diffuse Abdominal Pain 2: Hypogastric Abdominal Pain

A normal or non-tender abdominal exam is not reassuring in an elderly or immunocompromised patient, especially in the presence of systemic derangements like profound metabolic acidosis, which is a major red flag for an intra-abdominal catastrophe.

The clinical presentation can be dramatic, with the sudden onset of severe, diffuse abdominal pain, often described as the worst of their life.

Patients typically lie still to avoid any peritoneal movement.

The etiology of perforation is broad and includes peptic ulcer disease, diverticulitis, appendicitis, malignancy, or direct trauma.

Daily Pearl(s):

Peritonitis and Perforations

Secondary bacterial peritonitis results from the spilling of gastrointestinal contents into the normally sterile peritoneal cavity.

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Source: CPS - December 1, 2025 Neurology VMR with Dr. Helen Shi - Left hand weakness and numbness

Daily Pearl:

A significant discrepancy between a large vessel occlusion (ICA) and relatively mild, subcortical symptoms should raise suspicion for either a chronic, slowly progressive stenosis (like Moyamoya) or excellent acute collateral circulation.

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Source: CPS - December 1, 2025 Neurology VMR with Dr. Helen Shi - Left hand weakness and numbness

The RoPE (Risk of Paradoxical Embolism) score is a useful clinical tool to help quantify the probability that a PFO is the cause of a cryptogenic stroke, which can guide decisions regarding percutaneous closure.

Anatomic variants like May-Thurner syndrome (compression of the left common iliac vein by the right common iliac artery) can predispose individuals to DVT formation.

This condition should be suspected in younger patients (<60 years) who present with an ischemic stroke without traditional atherosclerotic risk factors or other clear etiology (cryptogenic stroke).

Daily Pearl(s):

Paradoxical Embolisms and PFOs

A paradoxical embolism occurs when a thrombus from the venous circulation passes into the arterial circulation through a right-to-left shunt, most commonly a PFO.

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In patients with poorly controlled hypothyroidism, a “second hit” like the introduction of a beta-blocker can precipitate life-threatening bradycardia.

Source: Diagnostic Atypia @Dx_Atypia Episode 21: Guestpisode! - Bradycardia

A positive response to atropine in a patient with severe bradycardia is a strong clue for a vagally-mediated etiology, a mechanism consistent with the effects of an extremely high TSH.

The proposed mechanisms include TSH-mediated modulation of cardiac potassium repolarization channels, which lengthens the cardiac action potential, and a significant increase in parasympathetic (vagal) tone, which slows conduction through the SA and AV nodes.

Daily Pearl:

Hypothyroidism and Bradycardia

A severely elevated TSH can cause profound bradycardia independent of free T4 levels through direct cardiac effects and increased parasympathetic tone.

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Cross-sectional imaging (CTA/MRA) is essential in the workup of obscure GI bleeding to evaluate the portal venous system when standard endoscopy is unrevealing.

Source: Case 36-2025 A 55-Year-Old Woman With Dyspnea, Fatigue, And Gastrointestinal Bleeding Case (NEJM)

The discordance suggests an underlying cause of platelet consumption or sequestration, such as hypersplenism.

In such cases, thrombocytopenia (or even low-normal platelets) in the setting of severe iron deficiency anemia is a clinical red flag, as iron deficiency typically causes reactive thrombocytosis.