Author: Kristopher Maday PA-C

PAINE #PANCE Pearl – Gastrointestinal

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Question

Ischemic bowel disease has two classic presentations: acute and chronic.

  1. What is the typical type of patient (or risk factors) for each?
  2. How does each type classically present?

Answer

  1. The risk factors for each type are a little different, but very important in differentiating the causes of abdominal pain:
    • Acute (from embolism)
      • atrial fibrillation, hypercoaguable states, instrumentation, valvular disease, and ventricular aneurysms
    • Chronic (from decreased perfusion)
      • peripheral vascular disease, atherosclerosis
  2. The presentations for both are also vastly different:
    • Acute
      • sudden onset of severe, periumbilical abdominal pain that is out of proportion to physical examination
      • bloody stools may also occur
    • Chronic
      • post-prandial intestinal pain due to inability to meet the blood flow demands for digestion
      • patients may also lose weight due to “food fear”

Ep-PAINE-nym

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Meckel’s Diverticulum

Other Known Aliases – none

Definition – Vestigial remnant of the omphalomesenteric (vitiline) duct

Clinical Significance – It is the most common malformation in the GI tract and is mainly asymptomatic.  When symptoms do occur, it commonly presents as painless, rectal bleeding in children.  The “Rule of 2s” will help you remember the facts of this pathology:

  • Effects 2% of the population
  • 2% of these will be symptomatic by age 2
  • 2 types of heterotopic tissue
  • Boy-to-girl ratio is 2:1
  • Usually 2″ in length
  • 2′ from the ileocecal valve

History – Named after Johann Friedrich Meckel, the Younger (1781-1833), who was a German anatomist and received his medical doctorate from the University of Halle in 1802. He then went on to become full professor of anatomy, surgery, and obstetrics at the University of Halle in 1808 after studying Würzburg, Vienna, and Paris. He made tremendous advancements in the area of anatomy and embryonic development with special attention to birth defects and abnormalities, where he pioneered the early study of teratology. He first published his eponymous finding in 1809 in an article entitled “Über die Divertikel am Darmkanal” in the Halle Archives of Physiology. Of note, he comes from a prestigous medical family, where both his father, grandfather, and brother were physicians….hence the surname “the Younger”.

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. Stallion A, Shuck JM.  Meckel’s Diverticulum.  Surgical Treatment: Evidence-Based and Problem-Oriented.  2001 [pubmed]
  7. Blackbourne LH.  Surgical Recall.  6th ed. 2012
  8. J. F. Meckel. Über die Divertikel am Darmkanal. Archiv für die Physiologie, Halle, 1809, 9: 421–453
  9. Klunker R, Göbbel L, Musil A, Tönnies H, Schultka R. Johann Friedrich Meckel the Younger (1781-1833) and modern teratology. Annals of Anatomy. 2002; 184(6):535-40. [pubmed]

Ep-PAINE-nym

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Rovsign’s Sign

Other Known Aliases – none

Definition – palpation of the left lower quadrant causes perceived pain in the right lower quadrant

Clinical Significance – A positive Rovsing’s sign is suggestive of appendicitis. There are two mechanisms that illicit this response. First, palpation of the left lower quadrant stretch the peritoneal lining over the appendix and causes pain. Second, deep palpation of descending colon in the left lower quadrant causes the gas present to stretch the lumen of the colon and appendix causing pain.

History – Named after Niels Thorkild Rovsing (1862-1927), who was a Danish surgeon and received his medical doctorate from the University of Copenhagen in 1885. He went on to become professor of operative surgery there in 1899, as well as chief surgeon at Louise-Børnehospital and Red Cross Hospital. He was a huge advocate for better surgical accommodations for patients, even going so far as to commission his own private surgical nursing home to care for his postoperative patients. He was international recognized as an accomplished abdominal surgeon, writing extensively on these surgical diseases. He first published his findings of his eponymous exam finding in 1907 in an article entitled “Indirect cause of typical pain at McBurney’s point”.

He also has several other surgical eponyms attributed to him including:

  • Rovsing Operation I and II for horseshoe kidney
  • Rovsing 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. Up To Date. www.uptodate.com
  6. N. T. Rovsing. Indirektes Hervorrufen des typischen Schmerzes an McBurney’s Punkt. Ein Beitrag zur diagnostik der Appendicitis und Typhlitis. Zentralblatt für Chirurgie, Leipzig, 1907, 34: 1257-1259.

PAINE #PANCE Pearl – Endocrine

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Question

47yo man presents to your clinic to establish care. He has a history of resistant hypertension, DMII, and sleep apnea. Vital signs are BP-159/101, HR-74, RR-16, O2-100%, and temp-98.9. Physical examination is also significant for multiple bruises on the lower extremities.

  1. What would be the next step in the diagnosis of this patient?
  2. What else would you need to order to determine the cause of this patient’s condition?

Answer

The initial SCREENING test of choice for Cushing Syndrome is a low-dose dexamethasone overnight suppression test. For this, 1mg dexamethasone is given around midnight and a serum cortisol is measured at 8am. A positive result is cortisol level of 1.8 mcg/dL.

The CONFIRMATORY test of choice for Cushing Syndrome is a 24-hour urinary cortisol excretion. A positive finding would be levels that are 3x the upper limit of normal for the assay used.

Once the diagnosis is made, the cause of the hypersecretion needs to be determined. For this, ordering a serum ACTH and high dose dexamethasone suppression test will help differentiate the various causes of the hypersecretion.

References

  1. Findling JW, Raff H, Aron DC. The low-dose dexamethasone suppression test: a reevaluation in patients with Cushing’s syndrome. The Journal of clinical endocrinology and metabolism. 2004; 89(3):1222-6. [pubmed]
  2. Dichek HL, Nieman LK, Oldfield EH, Pass HI, Malley JD, Cutler GB. A comparison of the standard high dose dexamethasone suppression test and the overnight 8-mg dexamethasone suppression test for the differential diagnosis of adrenocorticotropin-dependent Cushing’s syndrome. The Journal of clinical endocrinology and metabolism. 1994; 78(2):418-22. [pubmed]

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Addison’s Disease

Other Known Aliases – primary adrenal insufficiency

Definition – autoimmune destruction of the adrenal cortex that produces cortisol

Clinical Significance – In times of physiologic stress, the adrenal glands are unable to produce and secrete cortisol, which is a key hormone in the “fight-or-flight” response.  If the stress is significant (trauma, surgery, hemorrhage, etc.), then the patient can not mount a compensatory response to this stress and can have life-threatening consequences.

History – Named after Thomas Addison (1793-1860), an English physician who received his medical doctorate from the University of Edinburgh Medical School in 1815. He was a house physician at Guy’s Hospital and established himself as a prolific teacher and lecturer, often attracting physicians from all over London. He first described his eponymous disease in a short note in the London Medical Gazette called “Anaemia – Disease of the Suprarenal Capsules”.  This was then followed up by the more well known article “On the Constitutional and Local Effects of Disease of the Suprarenal Capsule” in 1855, which is largely considered the beginning of the study of the adrenal glands.  The disease eponym was original given to Dr. Addison by the French physician, Armand Trousseau, after fierce debate among experts as to whether the disease actually existed.

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. Pearce JM. Thomas Addison (1793-1860). Journal of the Royal Society of Medicine. 2004; 97(6):297-300. [pubmed]
  7. Addison T.  On the Constitutional and Local Effects of Disease of the Suprarenal Capsules.  1855.  London: Samuel Highley.

PAINE #PANCE Pearl – Endocrine

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Question

47yo man presents to your clinic to establish care. He has a history of resistant hypertension, DMII, and sleep apnea. Vital signs are BP-159/101, HR-74, RR-16, O2-100%, and temp-98.9. Physical examination is also significant for multiple bruises on the lower extremities.

  1. What would be the next step in the diagnosis of this patient?
  2. What else would you need to order to determine the cause of this patient’s condition?