Ochsner Medical Case Study
Presentation
An 85-year-old homeless male was brought in by the EMS in an unresponsive state. An EKG recorded in the Emergency Department is shown in the figures.
Questions
What is your diagnosis?
What is the diagnostic EKG sign called?
List the EKG changes commonly seen in this condition.
Name some other conditions where these EKG changes are seen.
This case study was prepared by Dr. Mohamed Khan, a fellow in Ochsner's Cardiology Department. The Ochsner Journal's Medical Case Studies are edited by Dr. Hector Ventura.
Ochsner Surgical Case Study
Presentation
A 48-year-old black female with a history of familial adenomatous polyposis (FAP) was evaluated by the Ochsner general surgery service with duodenal polyposis. She had a history of bleeding from the polyps intermittently but was otherwise asymptomatic. She had undergone resection of an abdominal wall desmoid tumor as well as duodenotomy with periampullary polyp removal. She had been followed on an annual basis with upper endoscopy. She had undergone total proctocolectomy with ileostomy creation in the 1970s for her FAP. Her father had also been diagnosed with FAP and had a total proctocolectomy. She has no other significant medical or surgery history.
Questions
What is the diagnosis?
What therapy is indicated for this patient?
This case study was prepared by Dr. David H. Hayes, a fellow in Ochsner's Surgery Department. The Ochsner Journal's Surgical Case Studies are edited by Dr. William Richardson.
Case Study Answers
Medical (from page118)
Hypothermia. This elderly homeless male, brought in on a winter night, had a core body temperature of 88 degrees Fahrenheit.
Osborne waves (also called J waves or “hypothermia hump”) are a deflection that appears as a late delta wave following the QRS. Although effects of cooling on the heart were described as early as 1923, J.J. Osborne systematically studied them in dogs and thought they were related to acidosis, which was later disproved. Vector cardiography in hypothermia patients reveals the mean vector of the Osborne wave to be directed anterior, inferior, and leftward, making these waves appear prominent in leads II, III, and AVF and lateral leads. Possible mechanisms include altered myocardial repolarization rates during cooling or altered epicardial action potential morphology resulting in a voltage gradient across the ventricular wall.
Common EKG manifestations of hypothermia include:
Prolonged PR interval
Sinus bradycardia
Prolonged QT interval
Atrial fibrillation
This pattern of nonischemic ST segment elevation is also seen in the following conditions:
Normal variant early repolarization
Brugada syndrome
Arrythmogenic RV dysplasia
Hypercalcemia
Subarachnoid hemorrhage
Surgical (from page 119)
Gardner's syndrome. The history of colon polyposis secondary to famialial adenomatous polyposis (FAP) is a significant historical factor. This in conjunction with duodenal polyps as well as dental abnormalities, desmoid tumors of the abdominal wall and mesentary, long bone abnormalities, and sebacious cysts help make the diagnosis of Gardner's syndrome. Colon polyposis as well as the duodenal polyps are well known to have malignant potential. Patients with FAP are recommended to have total proctocolectomy with ileoanal anastomosis. These patients should be screened with upper endoscopy as well to rule out gastric or duodenal polyps. Although gastric polyps have a very low potential for malignant change, the polyps in the duodenum need annual surveillance and removal via endoscopy to prevent malignant degeneration.
The indicated therapy for this patient is pancreaticoduodenectomy or the Whipple procedure. The patient, despite being followed endoscopically, had developed a history of bleeding from the polyps as well as periampullary polyps that were unresectable by the endoscopy. The removal of the duodenum resolved these issues. If the patient could be treated fully with endoscopy this also be a therapeutic option.
- Ochsner Clinic and Alton Ochsner Medical Foundation
