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.
What lab is likely to be profoundly elevated and what lab is most specific to this condition?
Definition – proximal 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.
History – Named 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
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.
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.
What are two (2) maneuvers that you should perform next?
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.
Other Known Aliases – BlackBerry thumb, mother’s wrist, washerwoman’s sprain
Definition – inflammation 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.
History – Named 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
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.
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.
What are two (2) maneuvers that you should perform next?
If these are positive, what would the most likely diagnosis be?
Definition – physical 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.
History – Named 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
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.
Definition – radiographic 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
History – Named 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
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.
Carcinoid lung tumors are a rare pulmonary malignancy and have classic, characteristics signs and symptoms associated with them.
What are the PULMONARY specific symptoms?
What are the classic SYSTEMIC symptoms of carcinoid syndrome?
Answer
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.
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
Definition – oscillating, 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.
History – Named 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
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.
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
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]
Gonlugur U, Gonlugur TE. The distinction between transudates and exudates. J Biomed Sci. 2005; 12(6):985-90. [pubmed]
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]
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]
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]
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]
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]
