Question
42yo G2P1001, who is 12-weeks gravid, presents to your office with concerns of public pain and a single episode of vaginal bleeding this morning. Physical examination reveals a gravid uterus with fundal height measured at the level of the umbilicus. Serum beta-hCG was found to be 745,223 mIU/mL. Ultrasound is below.
Zavanelli Manuever
Other Known Aliases – cephalic replacement, Gunn-Zavenelli-O’Leary Manuever
Definition – replacement of the fetal head back into the uterus followed by immediate cesarean delivery
Clinical Significance – this is a controversial, last resort maneuver to a shoulder dystocia and involves rotating the head back to an occiput anterior position, flexing the head , and pushing it as far cephalad as possible. The other hand can be used depress the perineum to relieve pressure on the umbilical cord. Although rarely used, single case reports do show a high rate of success.
History – Named after William Zavanelli (1926- ), an American obstetrician from California who received his medical doctorate from College of Osteopathic Physicians and Surgeons in Los Angeles in 1957. He would go on to have a modest career until 1978 when he performed his eponymous maneuver followed by a successful cesarean delivery. His partner wanted to publish the results immediately, but Zavanelli wanted to wait to see if there were any developmental issues with the child. After seven years, the case report was published. Of note, this manuever was performed 2 years prior by Gunn and his case report was published later in 1985 refuting the eponymous naming.
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Purkinje Fibers
Other Known Aliases – subendocardial branches
Definition – specialized conducting fibers composed of electrically excitable cells located just beneath the subendocardium in the inner ventricular walls of the heart
Clinical Significance – these cells actually conduct cardiac action potentials faster and more effeciently than any other cells in the heart and are responsible for the synchronized contractions of the ventricles during depolarization. They also have intrinsic pacemaking ability at 20-40 bpm to act as a back-up pacing system.
History – Named after Jan Evangelista Purkinje (1787-1869), a Czech anatomist and experimental physiologist who received his medical doctorate from Charles University in Prague in 1818. He would be appointed Professor of Physiology in Breslau in 1823 and did revolutionary work on vision. He would later create the world’s first Department of Physiology at the University of Breslau in Prussia in 1839 and the world’s second official physiology lab in 1842. During his career of physiologic discovery and research, he discovered large neurons with branching dendrites in the cerebellum (Purkinje cells), describe the change in brightness of red and blue colors as light intensity decreases (Purkinje shift), and the eye’s reduced sensitivity to dim red light compared to dim blue light (Purkinje effect). He also was the first scientist to present work on the cellular theory of biology, the first to use the term “protoplasm” to describe the fluid in cells, and the first to report on the individuality of fingerprints. But it was in 1839 when he described his eponymous fibers of the heart. He was one of the best known scientists of his era and was so famous, people would address letters to him and simply put “Purkinje, Europe”.
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Question
74yo woman, with a history of CAD and hyperlipidemia, presents to your office with a 6-month history of leg pain and swelling. She states that it seems to be worse when she is on her feet and improves when she can put her legs up. She denies worsening pain with activity or walking, but has recently developed a “rash” on her legs that is worrying her (see below). Physical examination reveals warmth to the feet and legs with scattered, thin hair. You appreciate 1+ DP and PT pulses bilaterally.
Bundle of His
Other Known Aliases – atrioventricular bundle
Definition – collection of electrical conduction cells of the heart that transmit impulses from the AV node to the ventricles
Clinical Significance – this bundle of cells is responsible for communication contraction impulses from the atria to the ventricles. Any damage to this area can result in varying degrees of heart block and conduction abnormalities
History – Named after Wilhelm His Jr. (1863-1934), a Swiss-born cardiologist and anatomist who received his medical doctorate from the University of Leipzig in 1889. The son of the equally famous Basel anatomist Wilhelm His Sr., he would become professor extraordinaire at his alma mater 6 year after graduating. He also went on to be physician-in-chief at the Friedrichstadt Hospital in Dresden, chair of internal medicine in Berlin, and advisory internist for several armies during World War I. He would describe his eponymous bundle as an assistant professor in 1893.
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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.
Answer
Beck’s Triad
Other Known Aliases – none
Definition – classic physical examination findings associated with critical cardiac tamponade
Clinical Significance – although not seen in every patient with cardiac tamponade, it is a common question on boards and certification examinations. These include: 1) hypotension, 2) JVD, and 3) muffled/distant heart sounds.
History – Named after Claude Schaeffer Beck (1894-1971), an American cardiac surgeon who recieved his medical doctorate from Harvard University in 1921. He would attend surgical residency at Case Western University, where he would spend his entire career. He developed a novel re-circulation technique for cardiac ischemia called the Beck Procedure, where pectoral muscle was implanted in the pericardium, and later placing a vein graft between the aorta to the coronary sinus. He also pioneered the first successful use of a defibrillator in 1947 to restore ROSC in a 14yo patient he was operating on for a congenital heart defect. His eponymous triad was first described in 1935 in an article entitled “Two cardiac compression triads” in the Journal of the American Medical Association.
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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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