PAINE #PANCE Pearl – Cardiology



Question

73yo man, with a history of hypertension and coronary disease, is brought into the emergency room after a witnessed syncopal episode at home. He reported some mild exertional chest pain over the past few days, but states that it improved with rest. Vital signs are BP-180/98, HR-74, RR-12, and O2-100%. He is currently in no distress and not diaphoretic. Physical examination revealed a systolic murmur over the 2nd right intercostal space. A CT was ordered to rule-out PTE in the setting of chest pain and syncope and is below, along with the murmur.

  1. What is the diagnosis?
  2. How would you describe this murmur?
  3. Where would you expect this murmur to radiate?
  4. What is the classic triad associated with this condition?

Answer

  1. Aortic Stenosis due to a calcified aortic valve
  2. High-pitched, crescendo-decrescendo (diamond shaped), midsystolic, ejection murmur with a soft S2
  3. AS murmurs transmit well and equally to the carotid arteries
  4. The classic triad of AS is exertional angina, exertional dyspnea, and dizziness/syncope

PAINE #PANCE Pearl – Cardiology



Question

73yo man, with a history of hypertension and coronary disease, is brought into the emergency room after a witnessed syncopal episode at home. He reported some mild exertional chest pain over the past few days, but states that it improved with rest. Vital signs are BP-180/98, HR-74, RR-12, and O2-100%. He is currently in no distress and not diaphoretic. Physical examination revealed a systolic murmur over the 2nd right intercostal space. A CT was ordered to rule-out PTE in the setting of chest pain and syncope and is below, along with the murmur.

  1. What is the diagnosis?
  2. How would you describe this murmur?
  3. Where would you expect this murmur to radiate?
  4. What is the classic triad associated with this condition?

PAINE #PANCE Pearl – Dermatology



Question

A 29yo patient is seen for a severe drug reaction after starting lamotrigine (Lamictal) for new-onset epilepsy. She has significant desquamation of her mucous membranes as well as large patches of denuded epidermis with multiple bullae present.

  1. What is the clinically distinguishing feature between Steven-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN)?

Answer

The main clinical difference between SJS and TEN is the severity and degree of involvement. SJS classically is < 10% TBSA involvement, where as TEN is > 30% TBSA.

PAINE #PANCE Pearl – Dermatology



Question

A 29yo patient is seen for a severe drug reaction after starting lamotrigine (Lamictal) for new-onset epilepsy. She has significant desquamation of her mucous membranes as well as large patches of denuded epidermis with multiple bullae present.

  1. What is the clinically distinguishing feature between Steven-Johnson Syndrome and Toxic Epidermal Necrolysis?

Ep-PAINE-nym



Le Fort Fractures

Other Known Aliasestransfacial fracture of the midface

DefinitionThese fractures involve the maxillary bone and are graded based on their direction and involvement of surrounding structures. The key distinguishing feature of this type of fracture is separation of the pterygoid plates from the maxillary sinuses.

Clinical Significance Continuity of the pterygoid plates is essential for midface structural stability and any disruption requires surgical fixation. There are three types of Le Fort fractures:

  1. Type I – Horizontal fracture – involves the lateral bony margin of the nasal opening
  2. Type II – Pyramidal fracture – involves the inferior orbital rim
  3. Type III – Transverse fracture – involves the zygomatic arch, vomer, and across the orbital floor and walls

HistoryNamed after René Le Fort (1869-1951), who was a French surgeon and received his medical doctorate at the age of 21 while serving in the French military. He taught and practice in Lille, France for the majority of his career. He served his country numerous times when called to serve as a military physician, as well as coming out of retirement during World War II to teach at the University of Lille to replace colleagues called to the war effort. He published the findings of his eponymous conditions in 1901 in a treatise entitled “Étude expérimentale sur les fractures de la mâchoire supérieure”, where he described his experiments of dropping cannon balls from varying directions and heights on the faces of cadavers to describe the predictable injury patterns


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. Gartshore L. A brief account of the life of René Le Fort. The British journal of oral & maxillofacial surgery. 2010; 48(3):173-5. [pubmed]
  7. Patterson R. The Le Fort fractures: René Le Fort and his work in anatomical pathology. Canadian journal of surgery. Journal canadien de chirurgie. 1991; 34(2):183-4. [pubmed]
  8. Le Fort R. Étude expérimentale sur les fractures de la machoire supérieure. Revue de chirurgie, Paris 1901; 23: 208-27; 360-79; 479-507

PAINE #PANCE Pearl – Critical Care



Question

A large part of critical care and ICU management revolves around hemodynamic monitoring and support. But…..we typically don’t use traditional blood pressure (systolic and diastolic) numbers directly.

We use MAP!!!

  1. What is MAP?
  2. How do you calculate it?
  3. Why is it a better variable to monitor when it comes to blood pressure and critical care?


Answer

  1. Mean Arterial Pressure (MAP)
  2. It is calculated using the following formula:
    1. MAP = 1/3(SBP) + 2/3(DBP)
  3. MAP has the greatest influence on blood flow autoregulation within the organs, as well as whole body hemodynamic homeostasis. It is superior to systolic pressure because it is the true driving pressure for peripherial blood flow and it does not change as the pressure waveform moves more distally.
    1. Bonus Pearl – MAP > 65 is a general ICU mantra as the minimum pressure pressure to maintain organ perfusion


References

  • Marino, PL. Arterial Pressure Monitoring. In: The ICU Book. 4th ed. 2014.
  • The relevance of the mean arterial pressure. From: Deranged Physiology – Monitoring of Arterial Pressure. [Link]
  • Mean Arterial Pressure. From: Cardiovascular Physiology Concepts. [Link]