62yo man, with a history of COPD and 52-pack-year history of smoking, presents to your office to establish care. His shortness of breath has been manageable using tiotropium daily with albuterol 2-3x per month for exacerbation. He denies angina, chest pain, or unreasonable dyspnea with exertion. An EKG was performed and is below.
What does it show?
What are the diagnostic criteria present?
Answer
The EKG reveals a right bundle branch block most likely due to his underlying COPD and pulmonary hypertension.
Diagnostic criteria for RBBB are:
Wide QRS > 120 ms
RSR’ pattern in V1-2 (“rabbit ears”) with R’ > R
Wide, slurred S wave in I, aVL, or V5-6
Other common findings, though not always associated, is ST depression and T wave inversion in the right precordial leads (V1-3)
Clinical Significance – although not seen in every patient with cardiac tamponade, it is a common question on boards and certification examinations. These include: 1) hypotension, 2) JVD, and 3) muffled/distant heart sounds.
History – Named after Claude Schaeffer Beck (1894-1971), an American cardiac surgeon who recieved his medical doctorate from Harvard University in 1921. He would attend surgical residency at Case Western University, where he would spend his entire career. He developed a novel re-circulation technique for cardiac ischemia called the Beck Procedure, where pectoral muscle was implanted in the pericardium, and later placing a vein graft between the aorta to the coronary sinus. He also pioneered the first successful use of a defibrillator in 1947 to restore ROSC in a 14yo patient he was operating on for a congenital heart defect. His eponymous triad was first described in 1935 in an article entitled “Two cardiac compression triads” in the Journal of the American Medical Association.
References
Firkin BG and Whitwirth JA. Dictionary of Medical Eponyms. 2nd ed. New York, NY; Parthenon Publishing Group. 1996.
Bartolucci S, Forbis P. Stedman’s Medical Eponyms. 2nd ed. Baltimore, MD; LWW. 2005.
Yee AJ, Pfiffner P. (2012). Medical Eponyms (Version 1.4.2) [Mobile Application Software]. Retrieved http://itunes.apple.com.
Beck CS. Two Cardiac Compression Triads. JAMA. 1935;104(9):714-716. [link]
Theruvath P, Ikonomidis JS. Historical perspectives of The American Association for Thoracic Surgery: Claude S. Beck (1894-1971). JTCVS. 2015;149(3):655-660. [link]
62yo man, with a history of COPD and 52-pack-year history of smoking, presents to your office to establish care. His shortness of breath has been manageable using tiotropium daily with albuterol 2-3x per month for exacerbation. He denies angina, chest pain, or unreasonable dyspnea with exertion. An EKG was performed and is below.
Definition – low-pitched, rumbling, mid-to-late diastolic murmur heard best at the apex
Clinical Significance – this murmur is associated with severe aortic regurgitation and is due to two distinct mechanisms. First, the aortic jet flow impinging on the mitral valve causing vibrations from premature closing and second, turbulence of two columns of blood from the left atrium to left ventricle and aorta to left ventricle.
History – Named after Austin Flint I (1812-1886), an American physician who received his medical doctorate from Harvard University in 1833. He would practice in Boston, Buffalo (where he would help found the Buffalo Medical College, and New York City, where he was professor of medicine at the famed Bellevue Hospital. A proponent of European diagnostic methods (as he was mentored by James Jackson at Harvard, who was a follower of Laënnec), he advocated and popularized the use of the binaural stethoscope in physical diagnosis. He was a prolific writer and researcher with his Treatise on the Principles and Practice of Medicine considered as a classic medical text. He is also recognized as having coined the term “broncho-vesicular breathing” in lung auscultation. He would publish the first detailed description his eponymous murmur in 1862 in the American Journal of Medicine Sciences in an article entitled “On cardiac murmurs”.
References
Firkin BG and Whitwirth JA. Dictionary of Medical Eponyms. 2nd ed. New York, NY; Parthenon Publishing Group. 1996.
Bartolucci S, Forbis P. Stedman’s Medical Eponyms. 2nd ed. Baltimore, MD; LWW. 2005.
Yee AJ, Pfiffner P. (2012). Medical Eponyms (Version 1.4.2) [Mobile Application Software]. Retrieved http://itunes.apple.com.
62yo man, with a history of pseudotumor cerebri, presents to your clinic with progressive headache and vision changes. You would like to confirm an increased intracranial pressure before sending him to the neurologist.
What are two (2) ways at the bedside you can confirm and what are the thresholds for positive findings?
Answer
The old and busted bedside way to determine if a patient has increased intracranial pressure is the fundoscopic examination. What you are looking for specifically is the cup:disc ratio of the optic nerve. Normal is around 0.3, or 1/3rd. If it is increased, it suggests increased intracranial pressure.
2. The new, hotness is using bedside POCUS to measure the optic nerve directly. Using the high frequency linear probe with a tegaderm placed over the patient eye, place a generous amount of gel over the globe and measure the optic nerve 3mm from the retina. A normal optic nerve should be < 5mm in diameter and anything over than suggests increased intracranial pressure
Definition – bedside test to evaluate hearing loss using a 512hz tuning fork
Clinical Significance – this maneuver is performed by vibrating a 512hz tuning fork and placing it on the mastoid process. The patient then informs the provider when they no longer can hear the ringing, at which point the tuning fork is moved in front of the canal. In normal hearing, the patient should still be able to hear the ringing (although it can also occur in sensorineural hearing loss). If conductive hearing loss is present, bone conduction is greater than air conduction.
History – Named after Heinrich Adolf Rinne (1819-1868), a German otologist who received his medical doctorate from the University of Göttingen. He would practice here for the majority of his career exploring the diseases of the ears, nose, and throat. He first described his eponymous test in 1855, but did not get widespread recognition for it until 1881 when it was further publicized by otologists Bezold and Lucae
References
Firkin BG and Whitwirth JA. Dictionary of Medical Eponyms. 2nd ed. New York, NY; Parthenon Publishing Group. 1996.
Bartolucci S, Forbis P. Stedman’s Medical Eponyms. 2nd ed. Baltimore, MD; LWW. 2005.
Yee AJ, Pfiffner P. (2012). Medical Eponyms (Version 1.4.2) [Mobile Application Software]. Retrieved http://itunes.apple.com.
Septal branch of the superior labial branch of the facial artery
Posterior
Woodruff’s Plexus
Posteriorlateral branches of the sphenopalatine artery
Posterior inferior turbinate
Epidemiology
Up to 60% of population will experience a significant nosebleed each year
Only 10% need to seek attention
Common ENT admission condition, but rarely needs surgical intervention
Bimodal age distribution
Before 10 years or between 45-65 years
Male predominance before the age of 49, then equalizes
Estrogen has been shown to protective for mucosa
Anterior bleeds are significantly more common (>90%) and resolve with minor interventions
Posterior bleeds can result in significant hemorrhage
Etiologies
Nose picking
Low environmental moisture
Mucosal hyperemia of viral or allergic rhinitis
Trauma
Foreign body
Anticoagulation
Coagulopathies
Osler-Weber-Rendu, von Willebrand, hemophilias
Connective tissue disease
Aneurysm development
Neoplasm
Squamous cell, inverted papilloma
Hypertension
Debated as a cause, but has shown to prolong bleeding
Nasal medications
Steroids, oxymetazoline
Heart failure
Patient Assessment
Primary
Airway assessment
RR, O2
Cardiovascular stability
HR, BP
Secondary
History
Medications
Anticoagulation, aspirin, nasal medications
PMH
Bleeding disorders, HTN, liver disease
Recent trauma
History of nosebleeds
How often, how long do they last, ever been admitted for one
Diagnostic Studies
Coagulation studies should NOT be routinely ordered
Should be in patients on anticoagulation
In patients with prolonged bleeds:
CBC
Type and cross
Examination
Have patient blow nose to remove clots and blood
Examine nasal cavity to see if you can see the bleeding site
Otoscope, nasal speculum
Don’t have patient tilt head back
Nasopharynx lies in anteroposterior plane and this will obscure the majority of the cavity from view
Interventions
Initial (Woodpecker/Walrus technique)
Have patient blow nose to remove clots
In a small basin mix any or all of the following:
Oxymetazoline
Lidocaine with epinephrine
Tranexamic acid
If available, soak GelFoam/Surgicel in this fluid and place BEFORE the sponge sticks
Trim two oral sponge swabs to better fit in the nasal cavity and soak in the fluid
Make a nasal bridge clamp by taping two tongue depressors together on one end
Place swabs in nasal cavities and apply nasal clamp for 10-15 minutes
Ice pack can also be used
Cautery
If the bleeding site can be visualized on direct examination
Apply topical anesthetic
Silver nitrate sticks
Start from periphery and roll to center of bleeding
No more than 10 seconds
A white eschar should form
Nasal packing
Use if cautery fails
Ensure topical anesthesia
Soak in sterile water
Insert by sliding along the floor of the nasal cavity PARALLEL to floor
Insufflate the balloon with air
Nasal Balloon Catheters
For posterior bleeds
Follow same steps for nasal packing
Insufflate posterior balloon FIRST and apply gently traction
Then insufflate the anterior balloon
Foley Catheters
If you don’t have a prefabricated nasal balloons, a foley catheter can work
Insert the catheter until you can see it in the posterior oropharynx
Insufflate with 5-10cc of water
Apply traction to seat balloon in posterior choana
Add additional water to tamponade
Clamp catheter with umbilical clamp or c-clamp from NG tube
Disposition and Follow-up
For simple nasal packing, patients should be evaluated by ENT within 24-48 hours
Discuss with consultant need for antibiotic prophylaxis
No good evidence supports routine use, but ENT often prefers
Amoxicillin-Clavulanate is most commonly used
Clindamycin or trimethoprim/sulfamethoxazole should be used if concern for nasal carrier of MRSA
Posterior bleeds should be immediately assessed by ENT for potential surgical intervention
Endoscopic sphenopalatine artery ligation
Anterior ethmoid artery ligation
Open or endoscopic
1893 Cottage Physician
References
Kucik CJ, Clenney T. Management of epistaxis. Am Fam Physician. 2005; 71(2):305-11. [pubmed]
Villwock JA, Jones K. Recent Trends in Epistaxis Management in the United States JAMA Otolaryngol Head Neck Surg. 2013; 139(12):1279-84. [pubmed]
Kotecha B, Fowler S, Harkness P, Walmsley J, Brown P, Topham J. Management of epistaxis: a national survey. Ann R Coll Surg Engl. 1996; 78(5):444-6. [PDF]
Fishpool SJ, Tomkinson A. Patterns of hospital admission with epistaxis for 26,725 patients over an 18-year period in Wales, UK. Ann R Coll Surg Engl. 2012; 94(8):559-62. [PDF]
Min HJ, Kang H, Choi GJ, Kim KS. Association between Hypertension and Epistaxis: Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg. 2017; 157(6):921-927. [pubmed]
Shakeel M, Trinidade A, Iddamalgoda T, Supriya M, Ah-See KW. Routine clotting screen has no role in the management of epistaxis: reiterating the point. Eur Arch Otorhinolaryngol. 2010; 267(10):1641-4. [pubmed]
Lin G, Bleier B. Surgical Management of Severe Epistaxis. Otolaryngol Clin North Am. 2016; 49(3):627-37. [pubmed]
62yo man, with a history of pseudotumor cerebri, presents to your clinic with progressive headache and vision changes. You would like to confirm an increased intracranial pressure before sending him to the neurologist.
What are two (2) ways at the bedside you can confirm and what are the thresholds for positive findings?
Other Known Aliases – Puestow-Gillesby procedure, lateral pancreaticojejunostomy
Definition – side-to-side anastomosis of the main pancreatic duct of Wirsung to the proximal jejunum
Clinical Significance – this is a surgical management option for patients with chronic pancreatitis by simultaneously facilitating drainage and preserving physiologic function of the pancreas.
History – Named after Charles Bernard Puestow (1902-1973), an American surgeon who recieved his medical doctorate from the University of Pennsylvania in 1925. He would serve as a military surgeon during the 2nd World War and commanded the 27th Evacuation Hospital providing surgical services to wounded soldiers in Europe and North Africa. His commitment to the veteran population would continue after the war when he established the first surgical residency program based in a veterans hospitals in the United States in 1946. It was at Hines Veterans Hospital in Illinois where he and his partner, William Gillesby, would publish their experience and outcomes on 21 patients with chronic pancreatitis in 1958, which would lead to the creation of his eponymonic surgical procedure.
References
Firkin BG and Whitwirth JA. Dictionary of Medical Eponyms. 2nd ed. New York, NY; Parthenon Publishing Group. 1996.
Bartolucci S, Forbis P. Stedman’s Medical Eponyms. 2nd ed. Baltimore, MD; LWW. 2005.
Yee AJ, Pfiffner P. (2012). Medical Eponyms (Version 1.4.2) [Mobile Application Software]. Retrieved http://itunes.apple.com.
Bosmia AN, Christein JD. Charles Bernard Puestow (1902-1973): American surgeon and commander of the 27th Evacuation Hospital during the Second World War. J Med Biogr. 2017; 25(3):147-152. [pubmed]
PUESTOW CB, GILLESBY WJ. Retrograde surgical drainage of pancreas for chronic relapsing pancreatitis. AMA Arch Surg. 1958; 76(6):898-907. [pubmed]
