PAINE #PANCE Pearl – Cardiology

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Question

A 5yo boy is brought to you clinic by his parents for reporting that his legs hurt “when he plays too much”. His parents corroborate this saying that when he is climbing on the playground for too long he complains that his legs hurt and he needs to stop and rest for awhile. Vaccinations are UTD and he has had a relatively healthy childhood without significant illnesses. He has no significant past medical history and mother reports that she was 38 weeks when he was born via NSVD without any complications. Cardiac auscultation reveals a normal S1 and S2 without murmurs, gallops, or rubs.

  1. What would you expect to find on physical examination?
  2. What other physical assessment can you perform at the bedside to help with the diagnosis?
  3. What findings on diagnostics would also help with the diagnosis?

Answer

The above scenario suggests coarctation of the aorta. The classic physical exam findings are hypertension in the upper extremities, delayed or dminished femoral pulses, and low or unobtainable blood pressures in the lower extremities. Thus, in patients you suspect coarctation of the aorta your should perform a supine bilateral brachial artery blood pressures and prone, supine popliteal blood pressure. In older children and adults, you may see rib notching on chest radiographs from development of large collateral arteries, as well as an indentation of the aortic wall at the site of the coarctation producing the class “3” sign.

Up-to-Date. 2020

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Prinzmetal angina

Other Known Aliases – variant angina

Definition – chest pain that occurs in the absence of exertion, often at rest and sometimes waking the patient up from sleep.

Clinical Significance – this type of angina classically is caused by vasospasm of the coronary vessels with or without superimposed antherosclerosis.

History – Named after Myron Prinzmetal (1908-1987), who was an American cardiologist and received his medical doctorate from UCSF School of Medicine in 1933. His career focused mainly on hypertension and heart dysrhythmias with over 160 publications to his name. He published the article describing his eponymous disease in 1959 entitled “Angina pectoris I: A variant form of angina pectoris”.

References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. PRINZMETAL M, KENNAMER R, MERLISS R, WADA T, BOR N. Angina pectoris. I. A variant form of angina pectoris; preliminary report. The American journal of medicine. 1959; 27:375-88. [pubmed]

PAINE #PANCE Pearl – Cardiology

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Question

A 5yo boy is brought to you clinic by his parents for reporting that his legs hurt “when he plays too much”. His parents corroborate this saying that when he is climbing on the playground for too long he complains that his legs hurt and he needs to stop and rest for awhile. Vaccinations are UTD and he has had a relatively healthy childhood without significant illnesses. He has no significant past medical history and mother reports that she was 38 weeks when he was born via NSVD without any complications. Cardiac auscultation reveals a normal S1 and S2 without murmurs, gallops, or rubs.

  1. What would you expect to find on physical examination?
  2. What other physical assessment can you perform at the bedside to help with the diagnosis?
  3. What findings on diagnostics would also help with the diagnosis?

Ep-PAINE-nym

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Takotsubo Cardiomyopathy

Other Known Aliases – Broken-Heart Syndrome

Definition – stress-induced cardiomyopathy

Clinical Significance – this syndrome is characterized by transient regional systolic dysfunction of the left ventricle, that mimics a myocardial infarction, but with an absence of angiographic evidence of coronary artery involvement.

History – Named after Japanese word for “octopus trap” as the left ventricle takes the shape of this unique hunting vessel. This condition was first studied in Japan by Hikaru Sato in 1991, but it was not “introduced” to the western medical world until 1997.

References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Tofield A. Hikaru Sato and Takotsubo cardiomyopathy. European Heart Journal, Volume 37, Issue 37, 1 October 2016, Page 2812
  7. Pavin D, Breton HL, Daubert C. Human stress cardiomyopathy mimicking acute myocardial syndrome. Heart. 1997;78:509-511.

PAINE #PANCE Pearl – Cardiology

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Question

73yo man, with a history of hypertension and coronary disease, is brought into the emergency room after a witnessed syncopal episode at home. He reported some mild exertional chest pain over the past few days, but states that it improved with rest. Vital signs are BP-180/98, HR-74, RR-12, and O2-100%. He is currently in no distress and not diaphoretic. Physical examination revealed a systolic murmur over the 2nd right intercostal space. A CT was ordered to rule-out PTE in the setting of chest pain and syncope and is below, along with the murmur.

  1. What is the diagnosis?
  2. How would you describe this murmur?
  3. Where would you expect this murmur to radiate?
  4. What is the classic triad associated with this condition?

Answer

  1. Aortic Stenosis due to a calcified aortic valve
  2. High-pitched, crescendo-decrescendo (diamond shaped), midsystolic, ejection murmur with a soft S2
  3. AS murmurs transmit well and equally to the carotid arteries
  4. The classic triad of AS is exertional angina, exertional dyspnea, and dizziness/syncope

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Kerley Lines

Other Known Aliases – none

Definition – lines seen on chest radiography due to interstitial edema

Clinical Significance – Kerley lines are thin pulmonary opacities caused by fluid or cellular infiltration into the interstitial of the lungs. There are three distinct types that are seen:

  • Kerley A lines – linear opacities extending from the periphery to the hilum caused by distention of anastomotic channels between peripheral and central lymphatics
  • Kerley B lines – short horizontal lines situated perpendicularly to the pleural surface at the lung base and represent edema of the interlobar septa
  • Kerley C lines – reticular opacities at the lung base representing Kerley B lines en face
White Arrows (A lines); White Arrowheads (B lines); Black Arrowheads (C lines)

History – Named after Sir Peter James Kerley (1900-1979), who was an Irish radiologist and received his medical doctorate from Cambridge University in 1932. He went on to study in Vienna, which was the center of the new and blossoming specialty of heart and lung radiography. He assisted to editing “A Textbook of X-ray Diagnosis” in 1939, which was a major radiology textbook at the time, and later became director of radiology at Westminster Hospital in 1939. He first described his eponymonic findings in an article entitled “Radiology in heart disease” in 1933, and further elaborated on them in the second volume of his textbooks in 1951. During this year, he was also a key figure in the diagnosing of King George VI’s lung cancer due to his review of the King’s radiographs. He received several Royal awards for mass radiological screening for tuberculosis and his diagnosis of King George VI cancer, leading up to his Knight Commander of the Royal Victorian Order by Queen Elizabeth in 1972.

References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Koga T, Fujimoto K. Images in clinical medicine. Kerley’s A, B, and C lines. The New England journal of medicine. 2009; 360(15):1539. [pubmed]
  7. Kerley P. Radiology in heart disease. BMJ. 1993;2:594-597 [Link]
  8. Shanks SC, Kerley P. A Text-Book Of X-Ray Diagnosis: Vol II. Saunders. 1951 pp403–415

PAINE #PANCE Pearl – Cardiology

Posted by

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Question

73yo man, with a history of hypertension and coronary disease, is brought into the emergency room after a witnessed syncopal episode at home. He reported some mild exertional chest pain over the past few days, but states that it improved with rest. Vital signs are BP-180/98, HR-74, RR-12, and O2-100%. He is currently in no distress and not diaphoretic. Physical examination revealed a systolic murmur over the 2nd right intercostal space. A CT was ordered to rule-out PTE in the setting of chest pain and syncope and is below, along with the murmur.

  1. What is the diagnosis?
  2. How would you describe this murmur?
  3. Where would you expect this murmur to radiate?
  4. What is the classic triad associated with this condition?