Answer to #FridayImageChallenge

You were correct! We see BOTH Westermark sign + Hampton hump

Great case and write-up below by: Drs. Allison Lange + Anurag Mehta (@anuragmehta09)

37yo previously healthy man presented with pleuritic chest pain, subjective SOB, hemoptysis. Found to be tachycardic to the 130s with EKG showing sinus tach, tachypneic to the mid 20s, BP 120s systolic on arrival. CXR with Westermarks sign and Hamptons hump.

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Common findings on CXR:
Westermark sign: sensitivity: ~14% , specificity: ~92%  dilation of the pulmonary artery proximal to an embolism with collapse of distal vessels (creating focal hyperlucency), the theory behind the sign is either obstruction of the pulmonary artery or distal vasoconstriction in hypoxic lung.

Hampton hump sensitivity: ~22% specificity: ~82% a dome-shaped, pleural-based opacification in the lung most commonly due to pulmonary embolism and lung infarction (it can also result from other causes of pulmonary infarction (e.g. vascular occlusion due to angioinvasive aspergillosis). While a pulmonary artery embolism is expected to result in a wedge-shaped infarction, the expected apex of this infarction may be spared because of bronchial arterial circulation in this part, leading to the characteristic rounded appearance of a Hampton hump.

Fleischner Sign is a prominent central artery that can be caused either by pulmonary hypertension that develops or by distension of the vessel by a large pulmonary embolus. Seen with massive PEs.

A CT was done with findings:

Left Sided Pulmonary Embolismuntitled

Right Sided Pulmonary Embolism
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Enlarged RV w/ septal flattening
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Bedside echo revealed right heart strain. Started on heparin gtt and admitted to MICU.

From PIOPED II study:

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EKG– signs of right heart strain: classically S1Q3T3 pattern, right axis deviation, p pulmonale

CT
Acute pulmonary thrombo-emboli can occasionally be detected on non-contrast chest CT as intraluminal hyperdensities 12.

CT pulmonary angiography (CTPA) will show filling defects within the pulmonary vasculature with acute pulmonary emboli. When observed in the axial plane this has been described as the polo mint sign. The central filling defect from the thrombus is surrounded by a thin rim of contrast, appearing like the popular sweet, the polo mint.

Echo: will see evidence of RV strain including systolic septal bowing and McConnells sign.

McConnell’s sign Echocardiographic pattern of RV dysfunction consisting of akinesia of the mid free wall but normal motion at the apex. 77% sensitivity and 94% specificity for diagnosis of pulmonary embolism.

Acute workup of PEuntitled

Treatment of acute PE
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Sources:
PIOPED II study
NEJM Acute Pulmonary Embolism 2010
Radiopaedia

#FridayImageChallenge

Another glorious Friday is upon us. And that means #FridayImageChallenge!

Case: 37 y/o previously healthy man presents with this CXR.

pe-picture

Resident Recognition

Props to our stellar Resident Bryan Park and Intern Shawn Simek, Wards-Team-Extraordinaire!!  They received a written letter of thanks and compliments from the spouse of one the patients under their care on the CUH Wards Eisenberg Service! Way to go guys!! Thank you to Dr. Rubin for sharing this note with us!🙂

Shout out also to our rising Superstar Jessy Barnes!! Words of praise from her attending: “She did a phenomenal job.  Despite being an intern, I would say the best resident I’ve ever had on service since I became an attending.  Very proactive.  Read up on stuff.  She critically evaluated patients and didn’t just go by what she was told by the ER or other services.  I was very happy and very impressed.” We are IMPRESSED!!🙂

Answer to #FridayImageChallenge

Well done! The answer to our #FridayImage was Myopericarditis.

We picked this case to discuss a differential for ST elevation on ECG. From a great NEJM paper from 2003 (ST-segment elevation in conditions other than acute myocardial infarction. Wang K, Asinger RW, Marriott HJ)

screenshot-2016-09-13-12-49-40

And then! What’s the difference between….

Myocarditis: inflammation of the heart muscle
Pericarditis: the inflammation of the lining outside the heart.
Myopericarditis: elevated troponin in the setting of pericarditis without new onset of focal or diffuse depressed LV function by echo or MRI
Perimyocarditis: with new onset of focal or diffused depressed LV function

Remember: Acute pericarditis: dx by the presence of 2 or more: chest pain, pericardial friction rub, ECG changes (diffuse ST-segment elevation or PR depression) and pericardial effusion.

Typical ECG: initially diffuse ST elevation and PR depression, followed by normalization of ST and PR segments, and then diffuse T-wave inversions

 

#FridayImageChallenge

Another week has passed and thanks to all those returning to our blog.

We present another #FridayImageChallenge. All cases provided by our very-own residents! Thanks this week to Spencer Carter, PGY2.

43yo man pmh HIV off HAART for 1 year presents w/ crushing substernal chest pain for the last 4 hours, worsens w/ exercise. He reports n/v/diarrhea for the last 4 days, unknown bloody vs. non-bloody.

ECG below: pericarditis

Answer to #FridayImageChallenge

Well done on your answers! The chest xray that you saw showed a L sided hiatal hernia – the left diaphragm is not visible while the right is. The bowel loops have crossed the midline (with an air bubble on top of the right heart border) and can be seen extending into the R hemithorax as well. You all probably wanted to get a Lateral xray…great though to differential an anterior/middle/posterior mediastinal mass.

The patient had further imaging done, a CT which revealed multiple loops of bowel that were located posterior to the heart and had filled the space normally occupied by the lungs. See image below:capture1

Thank you Anurag Mehta for the great case and images.

Our Pulmonogist and ICU director, Dr. Kershaw gave us a lecture on July 18 discussing mediastinal masses on imaging giving us a nice list. He says: “remember that lateral chest xrays can help you differentiate middle mediastinal masses, one of which is a hiatal hernia.”

Excerpt from his slides:

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And for BONUS: remember the 2 types of Congential Diaphragmatic Hernias (CDH)?

CDH is usually 95% posterolateral (Bochdalek hernia), but may be anterior retrosternal or peristernal (Morgagni hernia), or rarely central. ***mnemonic: Bochdalek is back and to the left***

hdm-netter1

Come back soon for another #FridayImageChallenge!

 

 

 

 

#FridayImageChallenge!

80 year old healthy hispanic lady who presented to the ED with gradually worsening SOB for the past 6 months. Her only other complaint was reflux symptoms that were not improving after almost a year of of treatment with pantoprazole.

You get a chest X-ray. What do you see?

Capture[1]

 

Resident Recognition!

Our residency program is like a large family. And like in any family, we want to recognize certain people for their recent work and accomplishments.

Brad Peden!

“I’m one of the fellows who had the pleasure of working with Brad Peden and wanted to give him due credit for his outstanding work ethics and attitude. Even for a busy rotation (a GI service) we have had an unusually busy month in terms of patient load. Although Brad is not interested in a career in GI, he never complained about staying late, always asked to help in whatever capacity he could, was always reliable, and was fun to work with on a team. He not only made an otherwise busy and draining month much easier for me, I’m certain his patients benefited from his work ethics as well. It is not an exaggeration when I say he is the best resident I have worked with thus far, and for that I thought he deserved recognition. Thanks!” Fellow on service

“I absolutely agree with [the fellow].  Brad is an excellent resident and should be recognized for this!” Attending on service

 

Let’s Talk About Resident Wellness

How do we change the culture of denial, secrecy, stigma and hopelessness surrounding seeking mental healthcare in residency??

Check out this powerful article from Dr. Elisabeth Poorman:

http://www.wbur.org/commonhealth/2016/08/19/depression-resident-doctor?utm_source=facebook.com

What do you think of her suggestions for battling depression amongst residents (near the bottom of the article)?

What can we adapt and bring to our own program?

 

Monomorphic vs. Polymorphic VT

Great job to those who answered our poll questions!

  1. What do you look at if called about possible NSVT and/or VT? Yes, all of the above. Look at QT duration, electrolytes (K and Mg), medications that prolong QT and low ejection fraction.
  2. The first image showed polymorphic VT, then post-cardioversion showed a normal QT –> making early ischemia or low EF much more likely – making the situation more dangerous. Please see below:

Screenshot 2016-08-19 10.21.28

ECG showing AV dissociation + capture beat + fusion beat

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AV Dissociation:  P waves appearing independently of the QRS complexes

Fusion beat: an impulse coming from above the atrioventricular node fusing with an impulse generated in the ventricle

Capture beat: reflect an impulse coming from above the atrioventricular node that depolarizes the ventricles when they are no longer refractory but before the next ventricle-generated complex

 

UTSW Internal Medicine

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