Question
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.
Austin Flint Murmur
Other Known Aliases – none
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”.
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Question
A 3yo girl is brought to your office by her parents for concern of asthma. They state that when she plays with her siblings, she often gets short of breath and needs to stop to rest for a few minutes. She is otherwise healthy and was born at 38 weeks gestation via cesarean section. She has had an uncomplicated past medical history and is up to date on all immunizations.
Physical examination reveals a well-nourished, well-developed girl, who is at 67% for height and 46% for weight for her age. Vital signs are BP-110/68, HR-87, RR-13, O2-100%, and temperature-98.7o. There is no evidence of cyanosis and auscultation findings are below.
Answer
2. This type of murmur and the above clinical features are most likely due to a patent ductus arteriosus.
3. After a Doppler echocardiogram has been performed, surgery would be the next step to close this defect. Pharmacologic therapy does not work as well in older infants and children. Transcatheter closure would be the preferred option given the patient’s age.
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Epidemiology
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Clinical Presentation
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Question
A 3yo girl is brought to your office by her parents for concern of asthma. They state that when she plays with her siblings, she often gets short of breath and needs to stop to rest for a few minutes. She is otherwise healthy and was born at 38 weeks gestation via cesarean section. She has had an uncomplicated past medical history and is up to date on all immunizations.
Physical examination reveals a well-nourished, well-developed girl, who is at 67% for height and 46% for weight for her age. Vital signs are BP-110/68, HR-87, RR-13, O2-100%, and temperature-98.7o. There is no evidence of cyanosis and auscultation findings are below.
Janeway Lesions
Other Known Aliases – none
Definition – non-tender, small erythematous or hemorrhagic lesions on the palms of the hands or soles of the feet.
Clinical Significance – these lesions are one of the classic, pathognomonic findings in infectious endocarditis. They are caused by septic emboli which deposit bacteria in the dermis of the skin causing microabscesses. In fact, cultures can be taken from these lesions.
History – Named after Edward G. Janeway (1841-1911), who was an American pathologist and received his medical doctorate from the College of Physicians and Surgeons in New York in 1864. He had a prolific career practicing in and around New York city primarily at Bellevue Hospital and served as Health Commissioner of New York from 1875-1882. He went on to become one of the founders of the Association of American Physicians in 1886, as well as president of the Academy of Medicine in 1897 and 1898. A contemporary of Sir William Osler, Janeway was regarded as one of America’s premier internists of the late nineteeth and early twentieth century. He first noted his eponymous finding in 1899 as a “peculiar skin lesion”, but the eponym was first coined by Emanuel Libman in 1906 and later explained in a footnote in an article in 1923.
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Question
A 5yo boy is brought to you clinic by his parents for reporting that his legs hurt “when he plays too much”. His parents corroborate this saying that when he is climbing on the playground for too long he complains that his legs hurt and he needs to stop and rest for awhile. Vaccinations are UTD and he has had a relatively healthy childhood without significant illnesses. He has no significant past medical history and mother reports that she was 38 weeks when he was born via NSVD without any complications. Cardiac auscultation reveals a normal S1 and S2 without murmurs, gallops, or rubs.
Answer
The above scenario suggests coarctation of the aorta. The classic physical exam findings are hypertension in the upper extremities, delayed or dminished femoral pulses, and low or unobtainable blood pressures in the lower extremities. Thus, in patients you suspect coarctation of the aorta your should perform a supine bilateral brachial artery blood pressures and prone, supine popliteal blood pressure. In older children and adults, you may see rib notching on chest radiographs from development of large collateral arteries, as well as an indentation of the aortic wall at the site of the coarctation producing the class “3” sign.
Prinzmetal angina
Other Known Aliases – variant angina
Definition – chest pain that occurs in the absence of exertion, often at rest and sometimes waking the patient up from sleep.
Clinical Significance – this type of angina classically is caused by vasospasm of the coronary vessels with or without superimposed antherosclerosis.
History – Named after Myron Prinzmetal (1908-1987), who was an American cardiologist and received his medical doctorate from UCSF School of Medicine in 1933. His career focused mainly on hypertension and heart dysrhythmias with over 160 publications to his name. He published the article describing his eponymous disease in 1959 entitled “Angina pectoris I: A variant form of angina pectoris”.
References
Question
A 5yo boy is brought to you clinic by his parents for reporting that his legs hurt “when he plays too much”. His parents corroborate this saying that when he is climbing on the playground for too long he complains that his legs hurt and he needs to stop and rest for awhile. Vaccinations are UTD and he has had a relatively healthy childhood without significant illnesses. He has no significant past medical history and mother reports that she was 38 weeks when he was born via NSVD without any complications. Cardiac auscultation reveals a normal S1 and S2 without murmurs, gallops, or rubs.
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