1/198. INR elevation associated with diarrhea in a patient receiving warfarin.OBJECTIVE: To report a case of international normalized ratio (INR) prolongation in a patient receiving warfarin who experienced several episodes of diarrhea. CASE SUMMARY: A 56-year-old white woman, previously controlled on warfarin therapy (INR 2.5-3.5) after aortic valve replacement, experienced six episodes of INR elevation, each associated with an acute bout of diarrhea lasting from one to four days. The patient had not received additional warfarin or new medications (including nonprescription medications and herbal remedies) prior to the episodes. The patient had no obvious signs of bleeding (except bruising on 1 episode) or signs of infection determined through physician evaluation of the patient and her stools. In addition, she had no diagnosis of liver disease or acute or chronic malabsorption. The patient did report that her dietary intake decreased to 25-50% of normal during these episodes of diarrhea, which may result in decreased vitamin k ingestion. DISCUSSION: This is one of the first case reports documenting a trend of INR elevation specifically with episodes of diarrhea. Since most of the common reasons for acute INR elevation have been eliminated, diarrhea with decreased oral intake are the most probable causes for these observed changes in the INR. Several reports suggest that acute diarrhea results in malabsorption of vitamin k, which can predispose patients taking warfarin to INR elevations, but in many of these reports patients had other risk factors for INR elevation. Although the effect of diarrhea on vitamin k absorption and the INR is difficult to quantify, the INR elevation reported here seemed to be directly associated with the duration of each diarrheal episode. CONCLUSIONS: diarrhea episodes in patients receiving warfarin can result in prolongation of the INR and possible bleeding. patients who experience diarrhea or decreased oral intake resulting in elevated INRs should have their INRs evaluated more frequently and their warfarin doses adjusted appropriately.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/198. Duplicate gallbladder cholecystitis after open cholecystectomy.A 42-year-old man presented with acute right upper quadrant abdominal pain 2 years after open cholecystectomy. Evaluation revealed cholecystitis in a second gallbladder and a second cholecystectomy was performed. Acute right upper quadrant abdominal pain after cholecystectomy presents a wide differential diagnosis, including the often idiopathic and difficult to manage postcholecystectomy syndrome. Emergency physicians should be aware of the most common causes of pain in these patients. Previously unrecognized congenital abnormalities of the biliary system should be considered when the diagnosis is not clear, as highlighted by this case report.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/198. Obstructive jaundice and acute cholangitis due to papillary stenosis.Papillary stenosis is characterized by fixed fibrosis leading to structural outflow obstruction and it is usually secondary to inflammation and fibrosis from the chronic passage of gallstones, episodes of acute pancreatitis, chronic pancreatitis, sclerosing cholangitis, peptic ulcer disease, and cholesterolosis. However, obstructive jaundice with or without acute cholangitis which leads the physician to suspect the presence of malignancy as a cause is a rare manifestation of papillary stenosis. We report here a case of papillary stenosis presenting with obstructive jaundice and acute cholangitis. The lesion was so difficult to exclude the presence of malignancy preoperatively and intraoperatively that a pylorus-preserving pancreaticoduodenectomy was performed. Histologic examination of the resected specimen revealed fibrosis, adenomatoid ductal hyperplasia, and mild chronic inflammation of the papilla of Vater and distal common bile duct.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/198. Neurogenic pulmonary oedema after generalized epileptic seizure.The diagnosis 'tonic clonic seizure' is frequently established by emergency physicians on scene. In patients with epilepsy mortality due to accidents, asphyxia, cardiac arrhythmias or postictal neurogenic pulmonary oedema (NPO) is twice as high as in the general population. We report a case of acute pulmonary oedema after a tonic clonic seizure. Following this event, the patient developed respiratory insufficiency and evidence of pulmonary oedema not associated with the classic aetiologies of congestive heart failure, aspiration or toxic exposure. The patient survived the incident after aggressive prehospital treatment, long-term intensive care and subsequent rehabilitation. A systematic case analysis and an introduction to the pathophysiology of NPO are presented. We recommend a positive approach to the management of NPO consisting primarily of interventions to stabilize vital functions, decrease intracranial pressure and normalize vegetative dysregulation. Emergency physicians need to consider the possibility of NPO in all cases of pulmonary oedema of unknown origin.- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |
5/198. Acute flank pain: an unusual presentation of a spinal AVM.The authors report the case of a 6-year-old boy with a spinal cord arteriovenous malformation (AVM) who presented with acute flank pain and a delayed onset of paraplegia. An early diagnosis of a spinal cord AVM was made difficult by the absence of neurological findings on initial evaluation. Included is a description of his clinical course, and the presentation of spinal AVMs to the emergency physician is discussed.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/198. pulmonary embolism.Despite the difficulty in diagnosis and the detailed care necessary in both the acute and long-term management of the patient with pulmonary embolism, expertise in this area is requisite for the primary care physician who may expect to encounter this problem with moderate frequency among patients in his clinical practice.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
7/198. Acute tubulo-interstitial nephritis requiring dialysis associated with intermittent rifampicin use: case report.Rifampicin is one of the most effective antibiotics used for the treatment of tuberculosis and severe staphylococcal infections. Intermittent administration of high doses of rifampicin has been associated with frequent adverse reactions, including hepatotoxicity and nephrotoxicity, sometimes resulting in acute renal failure. We describe a case of rifampicin-associated acute renal failure, with biopsy findings of tubulointerstitial nephritis; inflammatory cells were characterized by immunohistochemistry, which showed immunoreactivity for CD3 and CD5 (T lymphocytes) and for CD68 (macrophages). The patient presented with a very rapid systemic reaction to the offending drug and rapid deterioration of renal function, which required dialysis treatment. The response to rifampicin discontinuation was excellent: no further therapy was required, as renal function began to improve within several days and returned to normal values (serum creatinine 1.17 mg/dl) seven months after the onset of symptoms. When prescribing rifampicin the physician should investigate previous use of the drug, because re-exposure is a critical factor in predicting the possibility of drug-induced acute renal failure.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
8/198. Acute acalculous cholecystitis in a patient on total parenteral nutrition: case report and review of the Japanese literature.Acute acalculous cholecystitis (AAC) is a rare and dangerous complication of various medical and surgical conditions. We report on a male patient with bile panperitonitis caused by gangrenous AAC, which developed while he was on total parenteral nutrition (TPN) for ileus related to obstructive colon cancer. We also review the relevant Japanese literature on AAC associated with TPN. Our patient suddenly developed right hypochondrial pain after 3 days of TPN while waiting for colon cancer surgery. We diagnosed acute AAC by ultrasonography, and salvaged the patient by cholecystectomy plus left colectomy. early diagnosis by ultrasound is important for this critical condition. knowledge of the risk of acute gangrenous cholecystitis during TPN may allow the physician to provide an appropriate diagnosis and treatment.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
9/198. An unresponsive infant in the emergency room.The physician must be aware of the computed tomography appearance of an acute-hyperacute subdural hematoma in child abuse and not mistake it for chronic subdural hematoma with "spontaneous" rebleeding. As always, the imaging findings must be correlated with the clinical findings. Clinical and imaging findings of injury out of proportion to the history, and injuries of different ages are the key indicators to the possibility of child abuse, particularly when encountered in a young infant.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
10/198. Telemedical experiences at an Antarctic station.Wintering-over in Antarctica represents a physician's most remote and inaccessible scenario, apart from a space station. Because of the harsh and unpredictable winter weather, Antarctic stations are typically inaccessible for over six months of the year. telephone and fax communication, and recently other forms of telemedicine, have provided vital links to specialists. The author was the sole physician for more than 250 people wintering-over during the 1995 austral winter at McMurdo Station. There were several instances of serious or life-threatening illness where the author relied on teleconsultation. These cases included new-onset coronary artery disease, posterior hip dislocation, complicated colles' fracture and acute appendicitis. There were also numerous consultations for non-emergency clinical presentations normally managed by specialists. telemedicine was a crucial link to specialists from the remote and inaccessible environment of Antarctica.- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |
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