PAINE #PANCE Pearl – Cardiovascular



Question

 

64yo male, with a history of HTN, DMII, and hyperlipidemia, is brought in by EMS to the ED with a 2 hour history of lightheadedness and palpitations.  He states both these symptoms seem to fluctuate and nothing seems to make them better or worse when they occur.  He has never had anything like this before.  He denies syncope, chest pain, dyspnea, nausea, vomiting, diaphoresis, or vision changes.

 

Medications

Lisinopril 10mg

Metformin 1000mg

Simvastatin 20mg

 

Physical Exam

General – NAD, A&Ox3

HEENT – no diaphoresis, no gaze deviation, no facial palsies

CV – irregular, no M/G/R

Pulm – CTA bilaterally

MSK – 5/5 strength throughout

Neuro – CN II-XII grossly intact, MAE

 

While getting set up for a formal 12 lead EKG, the paramedic hands you the rhythm strips from transport:

 

What is the most likely diagnosis?

 

Ep-PAINE-nym



Corrigan’s Pulse

 

Other Known AliasesWatson’s water hammer pulse

DefinitionRefers to a pulse that is bounding and forceful, but also rapidly collapsing, resembling a Victorian water hammer toy.

Clinical SignificanceThis abnormality is due to increased stroke volume of the left ventricle and decrease in the peripheral resistance seen with aortic regurgitation.  Corrigan’s pulse classically refers to bounding carotid arteries and Watson’s water hammer pulse refers to radial arteries.

History – The two namesake’s for these findings are:

Sir Dominic John Corrigan (1802-1880), who was an Irish physician, received his medical doctorate from University of Edinburgh in 1825.  He was best known for his work ethic and experiments to further the knowledge of the symptomatology of heart disease.  He was also the first 5 time president of the Irish College of Physicians.  He published his findings of this pulse in 1832.

Dominic John Corrigan2crop.jpg

 

Sir Thomas Watson (1792-1882), was a British physician, received his medical doctorate from Cambridge University in 1825 and was inducted into the Royal College of Physicians in 1826.  He served as president from 1862-1866.  He studied and followed Corrigan’s work on the carotid artery findings in aortic regurgitation and studied the peripheral manifestations, which he published in 1844.


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. Suvarna JC. Watson’s water hammer pulse. Journal of postgraduate medicine. 2008;54(2):163-5. [pubmed]
  6. Corrigan DJ. On permanent patency of the mouth of the aorta, or inadequacy of the aortic valves. The Edinburgh Medical and Surgical Journal. 1832;37: 225-245

PAINE #PANCE Pearl – Cardiovascular



Question

 

What is the most common congenital heart defect seen in adults?

  • Ventricular Septal Defect (VSD)
  • Atrial Septal Defect (ASD)
  • Coarctation of the Aorta
  • Tetralogy of Fallot

 


Answer

 

Atrial septal defect (ASD) is the most common congenital heart defect that will be first diagnosed in adulthood with an incidence around 13% of all congenital heart defects.  Most are asymptomatic and are found during routine physical exams, by a presence of a murmur, or incidentally due to increased use of echocardiography in the clinical setting.


References

  1. Facts about Atrial Septal Defect.  Centers for Disease Control. 2016. https://www.cdc.gov/ncbddd/heartdefects/atrialseptaldefect.html
  2. Krasuski RA. Congenital Heart Disease in the Adult. Cleveland Clinic. 2010.  http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/cardiology/congenital-heart-disease-in-the-adult/
  3. van der Linde D, Konings EE, Slager MA. Birth prevalence of congenital heart disease worldwide: a systematic review and meta-analysis. Journal of the American College of Cardiology. 2011; 58(21):2241-7. [pubmed]

Ep-PAINE-nym



Starr-Edwards Valve

 

Other Known Aliasescaged-ball artificial heart valve

DefinitionOne of the first types of artificial heart valves produced.  When the pressure in the ventricle of the heart exceeds the pressure outside the ventricle, the ball is pushed against the cage and blood flows in.  After contraction, the pressure inside the ventricle drops below the outside of the ventricle and the ball moves back against the base, forming the seal.

Clinical SignificanceThis type of valve was one of the first to have long-term survival and you may still encounter these valves today because they were just discontinued in 2007.  Due to the make-up of the valve, patients needed to have INR levels from 2.5-3.5 to prevent thrombosis.

History – Named after Albert Starr (1926-) and Lowell Edwards (1898-1982), who were both noted American cardiovascular surgeons.  It was an interesting partnership as Starr was 30 years junior to Edwards at their initial meeting, but both had a passion for valvular research and worked well together.  The 1st valve was placed in August of 1960 and they went on to replace mitral valves in 8 patients that year and published their results in 1961.  This paper was voted one of the top 100 manuscripts of the 20th century and revolutionized valve surgery.

Related image

Edwards (Left) and Starr (Right)

Image result for albert starr

Starr (suit, middle)

scanned image of page 726


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. Matthews AM.  The development of the Starr-Edwards heart valve.  Tex Heart Int J.  1998;25(4):282-293
  6. Starr-Edwards Heart Valve.  The National Museum of American History
  7. Starr A, Edwards ML. Mitral Replacement: Clinical Experience with a Ball-Valve Prosthesis. Starr A, Edwards ML. Ann Surg 1961; 154: 726-740.

Ep-PAINE-nym



Levine’s Sign

 

Other Known AliasesPalm Sign, Cossio’s Sign, Cossio-Levine’s Sign

DefinitionClenched fist held over the sternum while a patient is describing their chest pain and classically is the right hand, as cardiac pain can refer to the left arm.

Image result for levine sign

Clinical SignificanceThere is very little significance to this sign and has been studied to only have a 14% sensitivity for cardiac chest pain, but is a classic physical exam finding and frequent pimp fodder.

History – Named after Samuel Albert Levine (1891-1966), who was an American cardiologist and attending physician at The Brigham Hospital in Boston, MA, and assistant professor of medicine at Harvard University.  He graduated Harvard at the age of 20 and was the first physician to diagnose President Franklin Roosevelt with poliomyelitis.  He was a pioneer in coronary thrombosis research and was the second physician to ever diagnose the condition, which he described it in his classic book Clinical Heart Disease in 1936. 

Samuel-Albert-Levine-1964.jpgImage result for samuel a levine

Image result for levine clinical heart disease

He is also the namesake of The Levine Scale, a 1 to 6 grading system to characterize the intensity  of heart murmurs, and Lown-Ganong-Levine syndrome, which is a pre-excitation syndrome causing a shortened PR interval with normal QRS complexes in tachycardia.

Image result for levine scale

The Levine Scale

Image result for lown ganong levine syndrome

Lown-Ganong-Levine Syndrome

 


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. Edmondstone WM. Cardiac chest pain: does body language help the diagnosis? BMJ. 1995;311(7021):1660-1. [pubmed]
  6. Levine HJ.  Profiles in Cardiology: Samuel A. Levine (1891-1966).  Clin Cardiol.  1992;15:473-476
  7. Bedford DE. Samuel Albert Levine (1891-1966). British heart journal. 1966; 28(6):853-4. [pubmed]
  8. Silverman ME, Wooley CF. Samuel A. Levine and the history of grading systolic murmurs. The American journal of cardiology. 2008; 102(8):1107-10. [pubmed]
  9. Lown B, Ganong WF, Levine SA. The syndrome of short P-R interval, normal QRS complex and paroxysmal rapid heart action. Circulation. 1952; 5(5):693-706. [pubmed]

PAINE #PANCE Pearl – Dermatology



Question

 

What are the 5 things to assess in a suspicious lesion/mole to evaluate for melanoma?

 



Answer

 

The ABCDEs of melanoma will help you identify suspicious lesions that will need dermatologic follow-up

 

Asymmetry

  • Draw a line through the lesion and the two halves do not look similar, it is concerning

Border Irregularity

  • If the borders of the lesion are not uniform and smooth, it is concerning

Color

  • Different colors within the same lesion are concerning

Diameter

  • ≥ 6 mm is concerning

Evolution

  • Any lesion that changes in size, shape, color is concerning

 

The is also another set of criteria that was developed in the UK by the United Kingdom National Institute for Clinical Excellence (NICE) and by the Scottish Intercollegiate Guidelines Network called the Glasgow Seven-point Checklist.  These guidelines incorporate 3 major and 4 minor criteria and any major or 3 minor criteria is an indication for referral.

Major

  • Change in size or new lesion
  • Change in shape
  • Change in color

Minor

  • Diameter ≥ 7mm
  • Inflammation
  • Crusting or bleeding
  • Sensory change


Once a patient has been referred to a dermatologist, they use a similar seven point system on dermoscopy to diagnose melanoma.

Major (2 points each)

  • Atypical pigment network
  • Blue-whitish veil
  • Atypical vascular pattern

Minor (1 point each)

  • Irregular streaks
  • Irregular pigmentation
  • Irregular dots/globules
  • Regression structures

 

A melonoma score of ≥ 3 is required for diagnosis

 



References

  1. National Collaborating Centre for Cancer (UK). Melanoma: Assessment and Management. London: National Institute for Health and Care Excellence (UK); 2015
  2. Scottish Intercollegiate Guidelines Network. Cutaneous Melanoma. A national clinical guideline. January 2017.
  3. Argenziano G, Fabbrocini G, Carli P, De Giorgi V, Sammarco E, Delfino M. Epiluminescence microscopy for the diagnosis of doubtful melanocytic skin lesions. Comparison of the ABCD rule of dermatoscopy and a new 7-point checklist based on pattern analysis. Archives of dermatology. 1998; 134(12):1563-70. [pubmed]
  4. http://www.dermoscopy.org/consensus/2d.asp