PAINE #PANCE Pearl – Pulmonary



Question

57yo woman presents to her primary provider’s office with a three week history of increasing dyspnea. She has a history of hypertension, cardiovascular disease, and COPD. Chest xray is below.

What are the two broad classifications of this findings and how do you differentiate between the two?



Answer

The two main classifications of pleural effusions are transudative and exudative.

To differentiate between the two, the pleural fluid is sent to the lab for composition testing and compared to the serum. According to Light’s Criteria, the effusion is transudative if:

  • Pleural/Serum protein ratio < 0.5
  • Pleural/Serum LDH ratio < 0.6
  • Pleural LDH < 2/3 the upper limit of normal serum LDH

Ep-PAINE-nym



Morgagni Hernia

Other Known Aliasesnone

Definitionanterior or retrosternal congenital diaphragmatic hernia

Clinical SignificanceThis is a rare type of congenital diaphragmatic hernias seen in only 2% of cases. It occurs through the foramina of Morgagni immediately adjacent and posterior to the xiphoid process.

HistoryNamed after Giovanni Battista Morgagni (1682-1771), who was an Italian anatomist and received his medical and philosophy doctorate from the University of Bologna in 1701 at the age of 19. He had a passion for studying anatomy and trained as a prosector for Antonio Valsalva at the Santa Maria della Morte hospital in Bologna. His reputation grew during this time and he was invited all over Europe to write about and teach anatomy. His greatest work would be “De Sedibus et causis morborum per anatomem indagatis” (Of the seats and causes of diseases investigated through anatomy”. This was a five book, two volume tome of his life’s work and is regarded as one of the founding works for modern pathological anatomy….if not one of the most fundamentally important works in the history of medicine.


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. Loukas M, El-Sedfy A, Tubbs RS, Gribben WB, Shoja MM, Cermakova A. Vincent Alexander Bochdalek (1801-1883). World journal of surgery. 2008; 32(10):2324-6. [pubmed]
  7. Bochdalek VA. Einige Betrachtungen über die Entstehung des angeborenen Zwerchfellbruches als Beitrag zur pathologischen Anatomie der Hernien. Vierteljahrschrift für die praktische Heilkunde. (Prag) 1848;19:89

PAINE #PANCE Pearl – Pulmonary



Question

57yo woman presents to her primary provider’s office with a three week history of increasing dyspnea. She has a history of hypertension, cardiovascular disease, and COPD. Chest xray is below.

What are the two broad classifications of this findings and how do you differentiate between the two?

Ep-PAINE-nym



Bochdalek Hernia

Other Known Aliasesnone

DefinitionPostero-lateral congenital diaphragmatic hernia

Clinical SignificanceThis type of congenital malformation can cause severe respiratory distress in a newborn as a result of compression on the lungs from herniated peritoneal contents. This is a surgical disease and infants are admitted to the NICU and supported via mechanical ventilation or ECMO until surgery can be planned.

HistoryNamed Vincent Bochdalek (1801-1883), who was a Bohemian anatomist and pathologist and received his medical doctorate from the University of Prague in 1833. He would later in his career return to his alma mater as a professor of anatomy for several decades where he earned is reputation as a prominent anatomist. He was a fervent advocate for establishing anatomy labs throughout Prague and was one of the founding physicians in the Prague School of Medicine. He was one of the pioneers in describing congenital diaphragmatic hernias in newborns and, unfortunately, there is little in the medical literature regarding him, but his eponym lives on. He published his extensive findings on his eponymous condition in 1848.


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. Loukas M, El-Sedfy A, Tubbs RS, Gribben WB, Shoja MM, Cermakova A. Vincent Alexander Bochdalek (1801-1883). World journal of surgery. 2008; 32(10):2324-6. [pubmed]
  7. Bochdalek VA. Einige Betrachtungen über die Entstehung des angeborenen Zwerchfellbruches als Beitrag zur pathologischen Anatomie der Hernien. Vierteljahrschrift für die praktische Heilkunde. (Prag) 1848;19:89

PAINE #PANCE Pearl – Pulmonary



Question

 

57yo man is referred to your practice due to an incidental 1.1cm single pulmonary nodule found on computed tomography.  He is a never smoker and denies any known family history of lung cancer.  He has no pulmonary medical history and reports no pulmonary symptoms.

 

Image result for single pulmonary nodule ct

 

What is the next step in the management of this patient?



Answer

 

  1. The first step in the management of this patient should be investigate if there are any previous studies to compare.  This will allow us to be able to assess if any growth has taken place.  For this patient, there are no previous studies to compare.
  2. The next step would be assess malignancy risk since it is larger than 8mm.  Up to Date uses the Brock University Cancer Equation, which I happen to like as well, though there are several out there and all use clinical, historical, and radiographical criteria.
  3. Our patient has a predicted malignancy risk of 3.54% and using the below algorithm, this patient needs a follow-up CT scan in 3 months to evaluate growth.



References

  1. Gould MK, Donington J, Lynch WR, et al. Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013; 143(5 Suppl):e93S-e120S. [pubmed]
  2. Callister ME, Baldwin DR, Akram AR, et al. British Thoracic Society guidelines for the investigation and management of pulmonary nodules. Thorax. 2015; 70 Suppl 2:ii1-ii54. [pubmed]
  3. McWilliams A, Tammemagi MC, Mayo JR, et al. Probability of cancer in pulmonary nodules detected on first screening CT. The New England journal of medicine. 2013; 369(10):910-9. [pubmed]
  4. Up-To-Date.  Diagnostic Evaluation of the Incidental Pulmonary Nodule.  2018.

Ep-PAINE-nym



Westermark’s Sign

 

Other Known Aliasesnone

 

Definitionfocal peripheral hyperlucency resulting from collapsed vessels distal to a pulmonary thromboembolism.

 

 

Clinical SignificanceOccurs as a result of oligemia of perfusion to the lung parenchyma and can be seen in up to 10% of patients with acute PTE.  Similar to Hampton’s Hump, it has a low sensitivity, but a high specificity

 

History – Named after Nils Johan Hugo Westermark (1892-1980), a Swedish radiologist who first described this finding in his 1938 paper entitled ” On the roentgen diagnosis of lung embolism”.  He was also an accomplished sailor and won a silver medal in the 1912 Olympics.

 

 


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. Krishnan AS, Barrett T. Images in clinical medicine. Westermark sign in pulmonary embolism. NEJM. 2012; 366(11):e16. [pubmed]
  7. Radiopaedia.  Westermark Sign. https://radiopaedia.org/articles/westermark-sign-1
  8. Westermark N. On the roentgen diagnosis of lung embolism. Acta Radiol 1938;19:357‑72.

PAINE #PANCE Pearl – Pulmonary



 

57yo man is referred to your practice due to an incidental 1.1cm single pulmonary nodule found on computed tomography.  He is a never smoker and denies any known family history of lung cancer.  He has no pulmonary medical history and reports no pulmonary symptoms.

 

Image result for single pulmonary nodule ct

 

What is the next step in the management of this patient?