4/5/17 Resident Morning Report – Aortic Stenosis

CC: chest pain, new murmur

ID: 60 yo male with no medical history was referred to the ED by his PMD for new murmur and bilateral leg swelling.  He reports chronic chest pain and dyspnea on exertion for the past year and an episode of syncope about 8 months ago.  Exam was notable for a III/VI systolic murmur heard throughout.  Patient underwent a TTE that demonstrated severe aortic stenosis.  He subsequently underwent surgical aortic valve replacement.

Don’t forget:

murmurs

adapted from MKSAP 17


Pearls from morning report:

  • Open surgical management of the aortic valve has traditionally been the preferred method of aortic valve replacement with TAVR reserved for those who were poor surgical candidates; however, in a recent study in NEJM, TAVR has been shown to be non-inferior to surgery.
  • Indications to obtain a TTE include a murmur > grade III/VI, continuous murmur, symptoms and/or the presence of a murmur, and a diastolic murmur.

Random trivia:

The first successful replacement of the aortic valve was performed and reported in 1960 by Dr. Harken.  Earlier surgical approaches to aortic valve disease were limited by the heart beating during the operation as cardiopulmonary bypass had not yet been developed.


Want to read more?

Aortic Stenosis (New England Journal of Medicine)
Aortic-Valve Stenosis – From Patients at Risk to Severe Valve Obstruction (New England Journal of Medicine)
2013 ACC/AHA Guideline for the Management of Heart Failure (Journal of the American College of Cardiology)


References: 

Reardon, MJ et al. Surgical or Transcatheter Aortic-Valve Replacement in Intermediate-Risk Patients. N Engl J Med. 2017;376(14):1321-1331.

MKSAP 17: Medical Knowledge Self-assessment Program. Philadelphia : American College Of Physicians, 2016. Print.

11/4/16 Intern Morning Report – Mediastinal Mass

CC: 3 weeks of chest pain and dry cough

ID: 56 yo female with migraines and uterine cyst presents with sharp, non-exertional chest pain and dry cough for the past 3 weeks.  She was found to have a mediastinal mass on CXR and 6% peripheral blasts.  Bone marrow biopsy revealed B-lymphoblastic leukemia/lymphoma.

cxr

ct

Don’t forget:

  • To evaluate whether a mass on an upright CXR arises from the mediastinum or the lung, consider the following:
    • does the mass seem to touch the mediastinum or heart border?
    • are the borders of the mass smooth and sharp (instead of spiculated)?
    • are the angles at which the mass meets the mediastinum obtuse?
    • are the borders of the mass smooth (instead of lobulated or undulating)?

If the above answers are “yes,” it suggests that the mass is mediastinal rather than from the lung.

  • The anterior, middle, and posterior mediastinal compartments are theoretical – there are no surgical or anatomical planes that create a clear division (hence, different radiology groups define each compartment a little differently).  Therefore, a mediastinal mass can be found in more than one compartment.

mediastinal-mass

Mediastinal Masses (PDF)


Pearls from morning report:

  • Lymphomas encase, but do not compress adjacent structures.
  • Not all malignancies will result in tumor lysis syndrome (TLS).  TLS is seen most frequently in high grade lymphomas, acute leukemia, and rapidly proliferating tumors
  • Indications for HD in TLS include hyperphosphatemia-induced symptomatic hypocalcemia, persistent hyperkalemia, and severe oliguria or anuria.

Random trivia:

Wilhelm Röntgen, a German physicist and mechanical engineer, produced and detected X-rays in 1895.  X-rays are named as such to signify an unknown quantity.  They are also known as roentgenograms (röntgenograms) – named in his honor.


Want to read more?

The Tumor Lysis Syndrome (New England Journal of Medicine)


References: 

Whitten CR, Khan S, Munneke GJ, Grubnic, S. A diagnostic approach to mediastinal abnormalities. Radiographics. 2007;27(3):657-71.