The Art of the Clinician

2021 ◽  
Vol 6 (09) ◽  
pp. 612-615
Author(s):  
Rodríguez-Guerra, Miguel, MD ◽  
Pandey, Neelanjana MD ◽  
Shrestha, Elina, MD ◽  
Vittorio, Timothy J. MD
Keyword(s):  
Correct Diagnosis ◽  
Critical Time ◽  
Mitral Valve Regurgitation ◽  
Intercostal Space ◽  
Av Fistula ◽  
Severe Aortic Regurgitation ◽  
Fibrin Sheath ◽  
Diastolic Murmur ◽  
Small Perforation ◽  
The Right

Background: The promotion of clinical abilities could represent a significant factor leading the clinicians to in making the correct diagnosis in a timely matter. Case: Our patient is a 42-year-old African male with a history of Hypertension, ESRD on hemodialysis via right-sided Permcath (PC), Mastoidectomy & Right ear surgery due to trauma in childhood, AV Fistula (Needed intervention 4 times) in left upper extremity, admitted due to witnessed seizures in the setting of hypertensive emergency. The patient denied family history and toxic habits. While the patient was at the emergency room, CT head revealed stable curvilinear hyper-attenuation thought to be a thrombosed developmental vein more likely than small subarachnoid hemorrhage. He was loaded with levetiracetam, received Ativan 1mg IV and HD done as per Nephrology. The patient was transferred to the floor he was not in acute distress and was asymptomatic, the cardiovascular (CV) examination showed regular pulse, normal S1, S2, S4+ appreciated with 2/4 diastolic murmur at second right intercostal space (ICS); 2/6 pansystolic murmur at third right intercostal space left parasternal border (LPSB) radiated to the right parasternal border (RPSB) and right mid-clavicular line (MCL); 3/6 systolic murmur at 5LICS MCL radiated to the posterior axillar line (PAL). Point of maximal impulse (PMI) displaced to mid axillar line (MAL). Parasternal heave present; the neurological exam was preserved. Endocarditis was suspected and echocardiogram was expedited, it showed severe aortic regurgitation, 1.60cm x 1.68cm mass in the tip of the catheter in the right atrium, possible vegetation in the tricuspid valve with mild regurgitation, moderate mitral valve regurgitation. Later, staphylococcus epidermidis was identified in blood cultures twice, as well as the culture from the PC. The transesophageal echocardiogram found 2.41 X 0.62 cm mass appears to be a fibrin sheath, possibly remnant of a prior catheter, small perforation in the non-coronary cusp likely in the setting of healed endocarditis. Infectious disease onboard for antibiotic management. Conclusion: The art of the clinician goes beyond the available technology; it could prevent the loss of critical time as well as unnecessary studies, guiding a better assessment and treatment of our patients and potentially improving their outcomes.

scholarly journals Pulsation of catheter during coronary angiography: Is it a sign of severe aortic regurgitation?

2021 ◽  
Author(s):  
Muzaffer Kahyaoglu ◽  
Cetin Gecmen ◽  
Ozkan Candan
Keyword(s):  
Coronary Angiography ◽  
Aortic Regurgitation ◽  
Ascending Aorta ◽  
Severe Aortic Regurgitation ◽  
Sternal Border ◽  
Diastolic Murmur ◽  
The Right ◽  
Diagnostic Catheter ◽  
Physical Findings ◽  
Flow Reversals

AbstractA 48-year-old male patient was admitted to our outpatient clinic with complaints of shortness of breath. He also had a holo-diastolic murmur at the right sternal border and an apical impulse being displaced laterally and inferiorly. Transthoracic echocardiography showed a severe aortic regurgitation without aortic valve stenosis and a mildly dilated left ventricle accompanied by an ejection fraction of 55%. The aortic regurgitation jet was eccentric and there were significant holodiastolic flow reversals in the descending thoracic aorta. Surgical management was advised for this patient because of symptomatic severe aortic regurgitation. Then, the patient underwent preoperative coronary angiography through the right femoral artery route. The left coronary ostium could be engaged with a 6 Fr Judkins left diagnostic catheter; however, the catheter jumped through the ascending aorta. Afterwards, the catheter was engaged and again jumped through the ascending aorta. Engagement and jumping cycles observed between successive systole to diastole. In our opinion, this catheter movement is explained by wide pulse pressure, like the severe characteristic physical findings of severe aortic regurgitation. Further studies are needed to understand whether this catheter movement is angiographically evidence of severe aortic regurgitation.

scholarly journals Cephalad misplacement of a pulmonary artery catheter in a patient with a preexisting Hickman catheter

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Hoon Choi ◽  
Joon Pyo Jeon ◽  
Jaewon Huh ◽  
Youme Kim ◽  
Wonjung Hwang
Keyword(s):  
Mitral Valve ◽  
Pulmonary Artery ◽  
Pulmonary Artery Catheter ◽  
Case Reports ◽  
Mitral Valve Regurgitation ◽  
Catheter Insertion ◽  
Routine Practice ◽  
Hickman Catheter ◽  
Risk Patients ◽  
The Right

Abstract Background Pulmonary artery catheter insertion is a routine practice in high-risk patients undergoing cardiac surgery. However, pulmonary artery catheter insertion is associated with numerous complications that can be devastating to the patient. Incorrect placement is an overlooked complication with few case reports to date. Case presentation An 18-year-old male patient underwent elective mitral valve replacement due to severe mitral valve regurgitation. The patient had a history of synovial sarcoma, and Hickman catheter had been inserted in the right internal jugular vein for systemic chemotherapy. We made multiple attempts to position the pulmonary artery catheter in the correct position but failed. A chest radiography revealed that the pulmonary artery catheter was bent and pointed in the cephalad direction. Removal of the pulmonary artery catheter was successful, and the patient was discharged 10 days after the surgery without complications. Conclusions To prevent misplacement of the PAC, clinicians should be aware of multiple risk factors in difficult PAC placement, and be prepared to utilize adjunctive methods, such as TEE and fluoroscopy.

scholarly journals A Case of Atypical Bartonellosis in a 4-Year-Old Immunocompetent Child

2021 ◽  
Vol 9 (5) ◽  
pp. 950
Author(s):  
Chiara Sodini ◽  
Elena Mariotti Zani ◽  
Francesco Pecora ◽  
Cristiano Conte ◽  
Viviana Dora Patianna ◽  
...  
Keyword(s):  
Clinical Laboratory ◽  
Bartonella Henselae ◽  
Delayed Diagnosis ◽  
Mitral Valve Regurgitation ◽  
Low Grade ◽  
Systemic Involvement ◽  
Mild Disease ◽  
Precise Diagnosis ◽  
Major Illness ◽  
The Right

In most cases, infection due to Bartonella henselae causes a mild disease presenting with a regional lymphadenopathy frequently associated with a low-grade fever, headache, poor appetite and exhaustion that spontaneously resolves itself in a few weeks. As the infection is generally transmitted by cats through scratching or biting, the disease is named cat scratch disease (CSD). However, in 5–20% of cases, mainly in immunocompromised patients, systemic involvement can occur and CSD may result in major illness. This report describes a case of systemic CSD diagnosed in an immunocompetent 4-year-old child that can be used as an example of the problems that pediatricians must solve to reach a diagnosis of atypical CSD. Despite the child’s lack of history suggesting any contact with cats and the absence of regional lymphadenopathy, the presence of a high fever, deterioration of their general condition, increased inflammatory biomarkers, hepatosplenic lesions (i.e., multiple abscesses), pericardial effusion with mild mitral valve regurgitation and a mild dilatation of the proximal and medial portion of the right coronary artery, seroconversion for B. henselae (IgG 1:256) supported the diagnosis of atypical CSD. Administration of oral azithromycin was initiated (10 mg/kg/die for 3 days) with a progressive normalization of clinical, laboratory and US hepatosplenic and cardiac findings. This case shows that the diagnosis of atypical CSD is challenging. The nonspecific, composite and variable clinical features of this disease require a careful evaluation in order to achieve a precise diagnosis and to avoid both a delayed diagnosis and therapy with a risk of negative evolution.

scholarly journals Percutaneous C-Arm Free O-Arm Navigated Biopsy for Spinal Pathologies: A Technical Note

Diagnostics ◽  
2021 ◽  
Vol 11 (4) ◽  
pp. 636
Author(s):  
Masato Tanaka ◽  
Sumeet Sonawane ◽  
Koji Uotani ◽  
Yoshihiro Fujiwara ◽  
Kittipong Sessumpun ◽  
...  
Keyword(s):  
Histopathological Examination ◽  
Correct Diagnosis ◽  
Standard Technique ◽  
Percutaneous Biopsy ◽  
Technical Note ◽  
Spinal Tumors ◽  
Histopathological Diagnosis ◽  
Ct Guided ◽  
Ct Guided Biopsy ◽  
The Right

Background: Percutaneous biopsy under computed tomography (CT) guidance is a standard technique to obtain a definitive diagnosis when spinal tumors, metastases or infections are suspected. However, specimens obtained using a needle are sometimes inadequate for correct diagnosis. This report describes a unique biopsy technique which is C-arm free O-arm navigated using microforceps. This has not been previously described as a biopsy procedure. Case description: A 74-year-old man with T1 vertebra pathology was referred to our hospital with muscle weakness of the right hand, clumsiness and cervicothoracic pain. CT-guided biopsy was performed, but histopathological diagnosis could not be obtained due to insufficient tissue. The patient then underwent biopsy under O-arm navigation, so we could obtain sufficient tissue and small cell carcinoma was diagnosed on histopathological examination. A patient later received chemotherapy and radiation. Conclusions: C-arm free O-arm navigated biopsy is an effective technique for obtaining sufficient material from spine pathologies. Tissue from an exact pathological site can be obtained with 3-D images. This new O-arm navigation biopsy may provide an alternative to repeat CT-guided or open biopsy.

scholarly journals P24: MANAGEMENT OF RHEUMATIC VALVE DISEASE OF THE AORTIC VALVE USING THE OZAKI PROCEDURE WITH AUTOLOGOUS PERICARDIUM

2021 ◽  
Vol 108 (Supplement_1) ◽  
Author(s):  
A Asif ◽  
M Caputo
Keyword(s):  
Aortic Valve ◽  
Intraoperative Complications ◽  
Valve Disease ◽  
Severe Aortic Regurgitation ◽  
Autologous Pericardium ◽  
End Diastolic Volume ◽  
Rheumatic Valve Disease ◽  
Coronary Cusp ◽  
Valve Pathology ◽  
Diastolic Murmur

Abstract Case-Study A 15-year-old boy was referred to our tertiary centre from his local paediatric services with a background of rheumatic fever, severe aortic regurgitation (AR) and mild to moderate mitral regurgitation. He had a history of angina and dyspnoea on exertion, a 2/6 ejection systolic murmur and 2/4 end diastolic murmur. Transthoracic echocardiography showed severe aortic valve insufficiency (with flow reversal seen in the descending aorta and an LV end diastolic volume of 173 ml/m2) and trivial pulmonary valve regurgitation. Autograft failure following the favoured Ross procedure deemed the patient as a candidate for an Ozaki procedure. Autologous pericardium was used to replace the diseased aortic valve. Intraoperative transoesophageal echocardiography showed a deficient left coronary cusp leaflet and a retracted right coronary cusp leaflet. The patient was under cardiopulmonary bypass for 124 minutes and on cross-clamping for 99 minutes with no intraoperative complications. Histological examination of the aortic valve leaflets showed neovascularisation, myxoid changes and disarray of the fibrous stroma. Postoperative recovery was uneventful. The postoperative echocardiogram showed trivial AR, end diastolic volume 217ml, end systolic volume 12 ml and 40% ejection fraction. There was full resolution of the dyspnoea, angina and diastolic murmur on follow-up 4-months postoperatively as supported by healthy valve function on echocardiography. This case highlights that in those of risk of multiple valve pathology, such as in rheumatic valve disease, an Ozaki procedure using autologous pericardium is a viable surgical option for paediatric aortic valve repair with good outcomes. Take-home message In cases of systemic conditions affecting the heart valves where there is multiple valve pathology and risk of autograft failure, such as rheumatic valve disease, the use of autologous pericardium to replace these valves has shown to be a viable option in this paediatric case.

Role of laparoscopic in diagnosis and treatment of undescended testis in children at Viet Duc Hospital

2018 ◽  
Vol 8 (4) ◽  
Author(s):  
Viet Hoa Nguyen
Keyword(s):  
Laparoscopic Surgery ◽  
Undescended Testis ◽  
Correct Diagnosis ◽  
Diagnosis And Treatment ◽  
Highly Sensitive ◽  
The Mean ◽  
The Right ◽  
Time Of Operation

Abstract Introduction: Evaluating the role of laparoscopic for diagnosis and treatment of undescended testis in children. Material and Methods: Restrospective study, between 6/ 2014 and 6/2017. All the patients are aged from 1 to 16 years with undescended testis underwent laparoscopic surgery for diagnosis and treatment in Deparment of pediatric surgery – Viet Duc hospital enrolled. Results: Of 95 patiens in total had 106 undescended testis diagnosed and treated by laparoscopy. The mean age of patients was 7,5 ± 3,8 years. 44,2% undescended were on the left side, 44,2% were on the right and 11,6% were undescended bilateral. The correct diagnosis by ultrasound accounted in 79,4%. The locations of testis diagnosed by laparoscopic are : intra abdomen in 45,3%, deep inguinal orifice in 16,9%, extra inguinal orifice in 26,4%, no testicle found in 11,4%. The mean time of operation were 67,33± 28,01 pht. Scrotal positions were achieved 74,5%, remove atrophic testis accounted in 7,6%. Stephen- Flowler technique including step I were in 4,7%, step II in 1,9%. The outcome evaluated by testicular positions following 3 months after operation are : good in 79,2%, moderate 13,2%, poor in 7,6%; By classification of Aubert are : good in 81,1%, moderate in 11,3% and poor in 7,6 %. Conclusion: Laparoscopic surgery is not only a highly sensitive diagnostic method to find accurately the location and size of the testes, but also the most effective method to treat impalpable undescended testes.

scholarly journals A Case of Multiple Posterior Intercostal Artery Common Trunks in Conjunction with Additional Arterial Variations

2021 ◽  
Vol 2021 ◽  
pp. 1-7
Author(s):  
Nicholas R. Fanselow ◽  
Nolan Wallace ◽  
Daniel Sehi ◽  
Lokesh Coomar ◽  
John Martin ◽  
...  
Keyword(s):  
Vertebral Artery ◽  
Intercostal Space ◽  
Thoracic Wall ◽  
Thoracic Cavity ◽  
Arterial Variation ◽  
Arterial Variations ◽  
First Case ◽  
Male Cadaver ◽  
The Right ◽  
High Level

Several thoracic vasculature variations were observed in an 81-year-old male cadaver during routine dissection. These included 5 common trunks of posterior intercostal arteries, a descending branch of the right vertebral artery, and atypical neurovascular relationships within intercostal spaces. On the right side, two common trunks of posterior intercostal arteries were observed supplying the 4th-7th intercostal spaces and 9th-11th intercostal spaces, respectively. There was also a small accessary branch supplying the 9th intercostal space. The first three posterior intercostal spaces on the right were supplied by a descending branch of the vertebral artery. On the left side, three common trunks of posterior intercostal arteries were encountered, supplying intercostal spaces 3-5, 6-7, and 11 plus the subcostal space. An atypical neurovascular relationship was observed in the right 6th intercostal space, as well as the left 2nd, 3rd, and 6th intercostal spaces. This is the first case report that presents 5 common trunks of posterior intercostal arteries, as well as common trunks in conjunction with other arterial variation in the posterior thoracic wall. These variations carry a high level of clinical significance and may be helpful in guiding decision-making related to surgical procedures related to the posterior thoracic cavity and spine.

scholarly journals Dynamic neuropathy of the common peroneal nerve at the level of the fibular head (literature review and case report)

2019 ◽  
Vol 21 (1) ◽  
pp. 54-59
Author(s):  
M. G. Bashlachev ◽  
G. Yu. Evzikov ◽  
V. A. Parfenov ◽  
N. B. Vuitsyk ◽  
F. V. Grebenev
Keyword(s):  
Ankle Joint ◽  
Peroneal Nerve ◽  
Correct Diagnosis ◽  
Clinical Manifestations ◽  
Common Peroneal Nerve ◽  
Diagnostic Methods ◽  
Fibular Head ◽  
Study Objective ◽  
The Common ◽  
The Right

The study objective is to report a case of dynamic neuropathy of the common peroneal nerve at the level of the fibular head and to discuss diagnostic methods and neurosurgical treatment. Materials and methods. We report a case of dynamic neuropathy of the common peroneal nerve at the level of the fibular head in a female patient. The patient was treated in the Neurology Clinic of I.M. Sechenov First Moscow State Medical University. We analyzed clinical manifestations and compared them with the data described in research literature. Results. Upon admission, the patient complained of pain in the anterolateral surface of the right shin and in the dorsum of the foot during walking. At rest, the patient experienced no pain. We observed no motor or sensory disorders typical of nerve root disorders at the level of L5. Lasegue’s test was negative. The patient had a positive Tinel’s sign in the area of the right fibular head. In order to clarify the diagnosis, we performed a repeated extension test in the right ankle joint and it was positive. The patient underwent surgery that included peroneal nerve decompression and neurolysis at the level of the fibular head. In the postoperative period, the patient had complete pain relief. Conclusion. Due to the difficulties in the diagnostics of dynamic neuropathy of the common peroneal nerve, this disease is often mistaken for radiculopathy at the level of L5. Thorough clinical examination, testing for Tinel’s sign in the area of the fibular head, and repeated extension test in the ankle joint ensure the correct diagnosis and reduce the frequency of ineffective surgeries on the lumbar spine. Surgical decompression of the common peroneal nerve at the level of the fibular head with obligatory opening of the entrance to the nerve canal is an effective method of treatment in such patients.

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