PAINE #PANCE Pearl – Rheumatology



Question

43yo woman, with a history of hypertension and GERD, presents to your clinic with a six month history of bilateral shoulder weakness that she first noticed when putting on sweaters and jackets and carrying in groceries. She denies any history of pain, repetitive trauma, or weakness in the hands. On physical examination, she has 3.5/5 strength in shoulder abduction and flexion, as well as the below rash. She reports the rash has been present for about the same time, but doesn’t really bother her.

  1. What lab is likely to be profoundly elevated and what lab is most specific to this condition?
  2. What is the most likely diagnosis?

Ep-PAINE-nym



Monteggia Fracture

Other Known Aliasesnone

Definitionproximal 1/3 ulnar fracture with radial head dislocation

Clinical Significance This type of injury pattern is most commonly seen with FOOSH injuries and is more common in children than adults with a peak incidence of 4-10 years of age. There are four different classifications depending on the injury pattern. There is also high incidence of neurovascular compromise and a good bedside exam is paramount prior to surgical repair.

HistoryNamed after Giovanni Battista Monteggia (1762-1815), who was an Italian surgeon and received his medical doctorate from the University of Pavia in 1789 at the age of seventeen. He would begin his career as a surgery apprentice at the Great Hospital in Milano in 1790 culminating in professor of anatomy and surgery in 1795. His knowledge of anatomy and skill as a surgeon impressed his a very famous colleague at the University of Pavia, one Antonio Scarpa. He published his eponymous injury in 1814 in his textbook entitled “Institziono Chirurgiche”. Of note, the first radiograph was not taken until 1895.


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. Orthobullets. Monteggia Fractures. https://www.orthobullets.com/trauma/1024/monteggia-fractures
  7. Monteggia GB. Instituzioni Chirurgiches. Vol. 5. Maspero; Milan, Italy: 1814.

PAINE #PANCE Pearl – Orthopaedics



Question

57yo woman comes into clinic complaining of a six-month history of right shoulder pain. She states that the pain is worse with overhead activities of the shoulder and when she is lifting and pulling with that arm. She has been more playing more tennis with her husband during this time as well, but has never had any other issues with this shoulder or arm before. She also reports painful arc of shoulder rotation with clicking that she feels on the anterior part of her shoulder. On physical examination, she has a negative drop arm and empty can test with no significant pain on resisted external rotation.

  1. What are two (2) maneuvers that you should perform next?
  2. If these are positive, what would the most likely diagnosis be?


Answer

Given the history and negative findings on rotator cuff maneuvers, the next two maneuvers shoulder be the Yergason and Speed tests. If the patient has pain with either of these then it suggests biceps tendonitis as the cause of their shoulder pain. Anatomically, the origin of the long head of the biceps is near the insertion of the supraspinatus tendon. This is why you always assess biceps tendonopathy in patient presenting with shoulder pain.

Ep-PAINE-nym



De Quervain Tenosynovitis

Other Known AliasesBlackBerry thumb, mother’s wrist, washerwoman’s sprain

Definitioninflammation of the abductor pollicis longus and extensor pollicis brevis tendons in the first extensor compartment at the styloid process of the radius.

Clinical Significance The pathogenesis is not well understood, but is most accepted to be caused by repetitive activities that maintain the thumb in extension and abduction. Treatment is graded from thumb spica splinting, NSAIDs, corticosteroid injections, up to surgical release of the first extensor compartment.

HistoryNamed after Fritz de Quervain (1868-1940), who was a Swiss surgeon and received his medical doctorate from the University of Bern in 1892. He would start his career training under Hugo Kronecker, Theodor Langhans, and Theodor Kocher, before becoming director of the surgical department at the La Chaux-de-fonds in Neuchâtel in 1897, and culminating in professor of surgery and director of the Inselspital at the University of Bern in 1918. He was a strong proponent of the generalist approach to patient care rather than the specialization of physicians and surgeons. He would describe his eponymous findings in his classic textbook series Spezielle chirurgische Diagnostik (Special Surgical Diagnosis) in 1907.


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. Spezielle chirurgische Diagnostik. Leipzig, 1907; 9th edition, 1931.

PAINE #PANCE Pearl – Orthopaedics



Question

57yo woman comes into clinic complaining of a six-month history of right shoulder pain. She states that the pain is worse with overhead activities of the shoulder and when she is lifting and pulling with that arm. She has been more playing more tennis with her husband during this time as well, but has never had any other issues with this shoulder or arm before. She also reports painful arc of shoulder rotation with clicking that she feels on the anterior part of her shoulder. On physical examination, she has a negative drop arm and empty can test with no significant pain on resisted external rotation.

  1. What are two (2) maneuvers that you should perform next?
  2. If these are positive, what would the most likely diagnosis be?

Ep-PAINE-nym



Finkelstein’s Test

Other Known AliasesEichoff’s test

Definitionphysical examination maneuver that is used to diagnose de Quervain’s tenosynovitis.

Clinical Significance this maneuver is performed by deviating the wrist in the ulnar direction while pushing the thumb towards the palm. A positive illicits pain along the radial aspect of the wrist along the abductor pollicis longus and extensor pollicis brevis tendons.

HistoryNamed after Henry Finkelstein (1883-1975), who was an American surgeon and recieved his medical doctorate from the College of Physicians and Surgeons in 1904. He would go on to have a modest career in orthopaedic surgery serving as a consultant at Beth Israel Hospital and chief of orthopaedic surgery at Trinity Hospital in Brooklyn, NY. He also was one of the original founding staff of the Hospital for Joint Diseases (now known as NYU Langone Orthopaedic Hospital). He published his eponymous maneuver in a manuscript entitled “Stenosing tendovaginitis at the radial styloid process” in 1930.


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. Finkelstein H. Stenosing tendovaginitis at the radial styloid process. The Journal of Bone and Joint Surgery, 1930, 12: 509-540 [link]
  7. https://www.nytimes.com/1975/01/25/archives/dr-harry-finkelstein-91-orthopedic-surgeon-dies.html

Ep-PAINE-nym



Ghon Focus and Complex

Other Known Aliasesnone

Definitionradiographic finding in primary tuberculosis where cellular and biochemical reaction to the infection forms a nodular granulomatous structure (focus) which can enlarge and invade adjacent lymphatics and hilar lymph nodes (complex).

Clinical Significance this finding on radiography is pathognomonic for primary active tuberculosis

HistoryNamed after Anton Ghon (1866-1936), who was an Austrian pathologist and recieved his medical doctorate from the University of Graz in 1890. He would spend his entire career in pathology and bacteriology culminating in full professorship at the University of Prague in 1910. He frist published his eponymous findings in his 1912 work entitled “Der primäre Lungenherd bei der Tuberkulose der Kinder”. Unfortunately, we would go on to die from tuberculous pericarditis in 1928


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. Der primäre Lungenherd bei der Tuberkulose der Kinder. Berlin & Wien, Urbach & Schwarzenberg, 1912.
  7. Ober WB. Ghon but not forgotten: Anton Ghon and his complex. Pathol Annu. 1983; 18 Pt 2:79-85. [pubmed]

PAINE #PANCE Pearl – Pulmonology



Question

Carcinoid lung tumors are a rare pulmonary malignancy and have classic, characteristics signs and symptoms associated with them.

  1. What are the PULMONARY specific symptoms?
  2. What are the classic SYSTEMIC symptoms of carcinoid syndrome?


Answer

  1. Carcinoid lung tumors typically arise in the proximal airways and patienta can have obstructing symptoms such as dyspnea, cough, wheezing, chest pain, and recurrent pneumonia due to impaired sputum clearance. These tumors are also hypervascular and hemoptysis is also common.
  2. Since carcinoid tumors are neuroendocrine tumors they produce and secrete a host of vasoactive substances that can cause a host of specific signs and symptoms. The classic presentation for carcinoid syndrome include flushing, telangiectasias, diarrhea, and bronchospasm

Ep-PAINE-nym



Cheyne-Stokes Respirations

Other Known Aliasesnone

Definitionoscillating, crescendo-decrescendo pattern of progressive deeper and faster breathing followed a gradual decrease culminating in a period of apnea

Clinical Significance this pattern is theorized to be a delay in changes to ventilation after detection of PaCO2 changes. This lag causes the classic respiratory pattern. Conditions associated with this include cardiac disease, neurologic disease, sedation, acid-base disturbances, prematurity in infancy, and rapid altitude changes.

HistoryNamed after John Cheyne (1777-1836) , who was a British surgeon and received his medical doctorate at the age of 18 from Edinburgh University. He would serve as a military surgeon for several years before joining his father’s medical practice and ultimately, moving to Dublin for the majority of his career. Some have credited him as “The Father of Medicine in Ireland”. He would describe his eponymous findings in his 1818 article entitled ” A case of apoplexy in which the fleshy part of the heart was converted to fat”

William Stokes (1804-1878), was an Irish physician and received his medical doctorate from the University of Edinbugh in 1825. He was a leader and pioneer in the adaptation of the Parisian school of anatomical diagnosis and helped introduce the stethoscope to clinical practice in Ireland. He would note his eponymous findings in his 1854 textbook entitled ” The Diseases of the Heart and Aorta” and cited Dr. Cheyne as observing this first.


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. Cheyne J. A case of apoplexy in which the fleshy part of the hear was converted into fat. Dubin Hospital Records. 1818;2:216-223. [link]
  7. Stokes W. The Diseases of the Heart and the Aorta. 1954. Dublin. [link]

#62 – Pleural Effusions



***LISTEN TO THE PODCAST HERE***



Pleural Anatomy and Physiology

  • 2 types of pleura in the thorax
    • Parietal pleura
      • Which covers the chest wall and diaphragm
      • 30-40 micrometers thick
      • Contains lymphatic stomata
        • Holes between the mesothelial and subpleural layers that allow for drainage into the lymphatic system
      • Contains intercostal microvessels
        • Produce interpleural fluid
    • Visceral pleura
      • Which covers the lung parenchyma
      • 20-80 micrometers thick
      • Contain bronchial microvessels
        • Arise from pulmonary veins and produce interpleural fluid
  • The interpleural space is between them and produces 0.1-0.2 mL/kg (10-20 mL per hemithorax) of fluid to keep these pleura from adhering to each other and maintain lubrication
    • This fluid is constantly produced (0.01 mL/kg/hr) and absorbed
    • Originates from the systemic pleural microvessels
      • Theorized that parietal is more important
        • Intercostal microvessels are closer to the interpleural space
        • Higher filtration pressure than pulmonary veins
    • Dependent on balance of hydrostatic pressure opposed by the counterbalancing osmotic pressure and membrane permeability
      • Transudative fluid collection
        • Increased hydrostatic pressure
        • Decreased oncotic pressure
      • Exudative fluid collection
        • Decreased pleural membrane permeability
        • Lymphatic blockage

Associated Diseases and Causes


Clinical Presentation

  • Symptoms      
    • Patients can be asymptomatic, have fluid specific symptoms, and have disease specific symptoms
    • Fluid specific
      • Dyspnea
      • Cough
      • Pleuritic chest pain
    • Disease specific
      • Fever, hemoptysis, orthopnea, peripheral edema, weight changes, ascites
  • Physical Examination
    • Fluid specific
      • Decreased or asymmetric chest wall movement
      • Decreased breath sounds
      • Dullness to percussion
      • Decreased tactile fremitus
      • Pleural friction rub
      • (+) egophony
    • Disease specific
      • Crackles, JVD, hepatosplenomegaly, lymphadenopathy, S3 gallop, pitting edema,

Imaging in Suspected Pleural Effusions

  • Chest Radiograph
    • Blunting of the costophrenic angle
      • At least 150mL needed on PA
      • At least 50mL needed on lateral decubitus
    • At least 500mL needed for diaphragm obliteration
  • Computed Tomography
    • Can detect as little as 2mL of fluid
  • Ultrasound
    • Can detect as little as 20mL
    • Phased array probe with patient sitting upright
    • Scan posterior/lateral caudal to cranial to find fluid line
    • (+) spine sign

Thoracentesis

  • Once the diagnosis is made, a thoracentesis needs to be performed for biochemical fluid analysis

Fluid Analysis

  • Routine fluid labs
    • Cell count and differential
    • pH
    • Protein
    • LDH
    • Glucose
    • Cholesterol
  • Non-routine
    • N-terminal BNP
    • Triglycerides
    • Creatinine
    • Amylase
    • Cancer-related biomarkers
  • Lights Criteria
    •  Exudative if one (1) of following present:
      • Pleural/serum protein ratio > 0.5
      • Pleural/serum LDH > 0.6
      • Pleural fluid LDH > 2/3rd ULN of serum LDH
    • Lights Criteria Criticism
      • Needs both pleural fluid and serum
      • Newer studies use only pleural fluid
        • Exudative if one (1) of the following:
          • Pleural fluid cholesterol > 45 mg/dL
          • Pleural fluid protein > 2.6 g/dL
          • Pleural fluid LDH > 0.45x ULN of serum LDH

Treatment

  • Non-malignant effusions
    • Treat underlying condition
    • Repeated drainage for symptomatic patients
    • If persistent:
      • Repeat thoracentesis as needed
      • Revisit primary diagnosis
      • Consider pleurodesis
        • Chemical
          • Talc slurry or doxycycline through chest tube
        • Mechanical
          • VATS
      • Indwelling pleural catheter
        • Reserved for patients who decline, fail, or not candidates for pleurodesis
  • Malignant effusions
    • Can be complicated

Cottage Physician (1898)



References

  1. Lai-Fook SJ. Pleural mechanics and fluid exchange. Physiol Rev. 2004; 84(2):385-410. [pubmed]
  2. Jantz MA, Antony VB. Pathophysiology of the pleura. Respiration. 2008; 75(2):121-33. [pubmed]
  3. Feller-Kopman D, Light R. Pleural Disease. N Engl J Med. 2018; 378(8):740-751. [pubmed]
  4. http://www.meddean.luc.edu/lumen/MedEd/medicine/pulmonar/apd/plep.htm
  5. Saguil A, Wyrick K, Hallgren J. Diagnostic approach to pleural effusion. Am Fam Physician. 2014; 90(2):99-104. [pubmed]
  6. Wong CL, Holroyd-Leduc J, Straus SE. Does this patient have a pleural effusion? JAMA. 2009; 301(3):309-17. [pubmed]
  7. Chesnutt AN, Chesnutt MS, Prendergast NT, Prendergast TJ. Pleural Effusion. In: Papadakis MA, McPhee SJ, Rabow MW. eds. Current Medical Diagnosis and Treatment 2020. McGraw-Hill; Accessed July 05, 2020. https://accessmedicine-mhmedical-com.ezproxy.uthsc.edu/content.aspx?bookid=2683&sectionid=225058693
  8. Light RW. Disorders of the Pleura. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. eds. Harrison’s Principles of Internal Medicine, 20e. McGraw-Hill; Accessed July 05, 2020. https://accessmedicine-mhmedical-com.ezproxy.uthsc.edu/content.aspx?bookid=2129&sectionid=192031615
  9. Moskowitz H, Platt RT, Schachar R, Mellins H. Roentgen visualization of minute pleural effusion. An experimental study to determine the minimum amount of pleural fluid visible on a radiograph. Radiology. 1973; 109(1):33-5. [pubmed]
  10. Radiopaedia. Pleural Effusions. https://radiopaedia.org/articles/pleural-effusion?lang=us
  11. Gonlugur U, Gonlugur TE. The distinction between transudates and exudates. J Biomed Sci. 2005; 12(6):985-90. [pubmed]
  12. Heffner JE, Brown LK, Barbieri CA. Diagnostic value of tests that discriminate between exudative and transudative pleural effusions. Primary Study Investigators. Chest. 1997; 111(4):970-80. [pubmed]
  13. Steger V, Mika U, Toomes H, et al. Who gains most? A 10-year experience with 611 thoracoscopic talc pleurodeses. Ann Thorac Surg. 2007; 83(6):1940-5. [pubmed]
  14. Patil M, Dhillon SS, Attwood K, Saoud M, Alraiyes AH, Harris K. Management of Benign Pleural Effusions Using Indwelling Pleural Catheters: A Systematic Review and Meta-analysis. Chest. 2017; 151(3):626-635. [pubmed]
  15. Feller-Kopman DJ, Reddy CB, DeCamp MM, et al. Management of Malignant Pleural Effusions. An Official ATS/STS/STR Clinical Practice Guideline. Am J Respir Crit Care Med. 2018; 198(7):839-849. [pubmed]
  16. Bibby AC, Dorn P, Psallidas I, et al. ERS/EACTS statement on the management of malignant pleural effusions. Eur Respir J. 2018; 52(1):. [pubmed]