1/20. syncope caused by nonsteroidal anti-inflammatory drugs and angiotensin-converting enzyme inhibitors.A 85-year-old woman with diabetes mellitus and prior myocardial infarction was transferred to the emergency room with loss of consciousness due to marked bradycardia caused by hyperkalemia. The T wave during right ventricular pacing was tall and tent-shaped while the concentration of serum potassium was high, and its amplitude during pacing was decreased after correction of the serum potassium level. Simultaneously with the correction, normal sinus rhythm was restored. The cause of hyperkalemia was considered to be several doses of loxoprofen, a nonsteroidal anti-inflammatory drug (NSAID), prescribed for her lumbago by an orthopedic specialist, in addition to the long-term intake of imidapril, an angiotensin-converting enzyme inhibitor (ACEI), prescribed for her hypertension by a cardiologist. This case warns physicians that the combination of NSAID and ACEI can produce serious side effects in aged patients who frequently suffer from hypertension, diabetes mellitus, ischemic heart disease, and degenerative joint disease.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/20. Electrocardiographic changes in hypothermia.With the clinical use of cold cardioplegia, or total body hypothermia, it is crucial that critical care physicians and nurses be aware of the electrocardiographic changes related to hypothermia. Similar changes also occur with accidental exposure to cold. We report and discuss a patient who presented with typical electrocardiographic changes upon accidental exposure to cold.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/20. gout, bradycardia, and hypercholesterolemia after renal transplantation.Approximately 17,000 solid organ transplantations are done annually in the united states. Increasingly, care of these patients will be provided by primary care physicians. In this report, we illustrate the complexity of common medical problems in a patient who had cellulitis and who had had a cadaveric renal transplantation 10 years earlier. Immunosuppressive therapy was cyclosporine (100 mg twice a day) and prednisone (10 mg once a day). The patient's hospital course was complicated by acute gout and symptomatic bradycardia. In both instances, usual treatment--full-dose indomethacin for gout and withholding verapamil for bradycardia--could have had significant interaction with the cyclosporine. At the time of discharge, a therapeutic plan for long-term management of hypercholesterolemia included possible drug interactions with cyclosporine. The potential for drug toxicity in the transplant patient necessitates careful monitoring of immunosuppressive drug levels. Ongoing communication with the transplant center is also needed.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/20. Toxicity of over-the-counter cough and cold medications.Over-the-counter (OTC) cough and cold medications are marketed widely for relief of common cold symptoms, and yet studies have failed to demonstrate a benefit of these medications for young children. In addition, OTC medications can be associated with significant morbidity and even mortality in both acute overdoses and when administered in correct doses for chronic periods of time. physicians often do not inquire about OTC medication use, and parents (or other caregivers) often do not perceive OTCs as medications. We present 3 cases of adverse outcomes over a 13-month period-including 1 death-as a result of OTC cough and cold medication use. We explore the toxicities of OTC cough and cold medications, discuss mechanisms of dosing errors, and suggest why physicians should be more vigilant in specifically inquiring about OTCs when evaluating an ill child.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
5/20. Toad venom poisoning: resemblance to digoxin toxicity and therapeutic implications.A healthy man developed gastrointestinal symptoms after ingesting purported aphrodisiac pills. He had severe unrelenting bradycardia, hyperkalaemia, and acidosis. He rapidly developed severe life threatening cardiac arrhythmias and died after a few hours. He was found to have positive serum digoxin concentrations, although he was not taking digoxin. Toad venom poisoning is similar to digitalis toxicity and carries a high mortality. Cardiac glycoside poisoning can occur from ingestion of various plants and animal toxins, and the venom gland of cane toad (bufo marinus) contains large quantities of cardiac glycosides. Toad venom, a constituent of an aphrodisiac, was considered responsible for the development of clinical manifestations and death in this patient. digoxin specific Fab fragment has been reported to be beneficial in the treatment of toad venom poisoning. This report alerts physicians to the need to be aware of a new community toxic exposure, as prompt treatment with digoxin specific Fab fragment may be life saving. The treatment approach to patients with suspected toad venom poisoning is described.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/20. octreotide-induced bradycardia and heart block during surgical resection of a carcinoid tumor.octreotide may be a life-saving treatment in the case of an acute carcinoid crisis, but when given as an i.v. bolus in larger doses, it may cause significant effects on the cardiac conduction system. We describe cardiac conduction impairment observed during octreotide administration in a patient undergoing carcinoid tumor surgery. In this patient, i.v. boluses of 100 microg of octreotide resulted in symptomatic bradycardia, Mobitz type II atrioventricular block, and complete heart block. Perioperative physicians especially need to be aware of these potential effects because they may be more likely to occur during surgery because of the larger doses and boluses that are used to treat acute symptoms secondary to tumor manipulation. IMPLICATIONS: In some susceptible patients, i.v. bolus administration of octreotide may cause significant bradycardia and cardiac conduction defects. Therefore, when octreotide is administered as a bolus, it may be advisable to give it slowly while monitoring the electrocardiogram.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
7/20. Systemic anaphylaxis following local lidocaine administration during a dental procedure.We report a 4-year-old child who developed systemic anaphylactic reaction to lidocaine hydrochloride within 15 minutes after a dental procedure. hypersensitivity to local anesthetics is not common; however, if anaphylaxis did happen, it required emergent and immediate resuscitation. To prevent such complications, complete medical history including drug allergy should be taken. Prompt administration of epinephrine and other resuscitative measures are life saving in such circumstance. All emergency room physicians should consider systemic anaphylaxis in patients with rapid vascular collapse and respiratory failure immediately following lidocaine administration for minor outpatient procedures.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
8/20. Reevaluating spells initially identified as cataplexy.BACKGROUND AND PURPOSE: cataplexy, transient episodes of bilateral muscle weakness with areflexia provoked by emotions, is a state highly specific to narcolepsy. cataplexy is diagnosed based on clinical interview. Two screening tools have been developed recently but their usefulness has been limited because of length or current lack of psychometric data. Used effectively even these screening tests require the interpreting physician to have an understanding of the typical features of cataplexy. Most physicians encounter patients with cataplexy fairly infrequently, making it difficult to gain proficiency in detecting cataplexy based on clinical interview alone. Relatively little attention has been given to the differential diagnosis of cataplexy, which increases the likelihood of unnecessary sleep testing or false positive diagnosis. patients AND methods: This case series describes six cases where cataplexy was initially diagnosed. In all cases the weakness spells were eventually not attributed to cataplexy. The presentation and characteristics of these cases will be presented as a means to discuss the differential diagnosis of cataplexy. RESULTS: These cases represent a diverse set of medical disorders including bradycardia, migraine, delayed sleep phase syndrome, conversion disorder, malingering and a chronic psychotic disorder. CONCLUSIONS: A more in-depth understanding of the classic features of cataplexy should improve recognition of this fascinating state. Improved cataplexy recognition will enhance the appropriate usage of sleep tests and eventually increase the timeliness and accuracy of the diagnosis of narcolepsy with cataplexy.- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |
9/20. Near-fatal amitraz intoxication: the overlooked pesticide.Amitraz is commonly used in agricultural industries throughout the world as a farm-animal insecticide. Despite its widespread use, amitraz intoxication is extremely rare and mainly occurs through accidental ingestion by young children. Severe, life-threatening amitraz intoxication in adults is very rarely recognized and reported. Described herein is a previously healthy 54-year-old patient who accidentally ingested a mouthful of liquid amitraz concentrate, and rapidly developed life-threatening clonidine-like overdose syndrome, manifested as nausea, vomiting, hypotension, bradycardia, bradypnoea, and deep coma. Supportive treatment, including mechanical ventilation, and atropine administration resulted in full recovery within 48 hr. Very few cases of near-fatal amitraz poisoning in adults have been described in the medical literature, leading to low awareness of physicians in general practice to the potential toxicity of amitraz. As a consequence, cases of amitraz poisoning are not recognised and therefore erroneously treated as the much more commonly recognized organophosphate and carbamate intoxication. In our discussion, we review the clinical and laboratory manifestations of amitraz poisoning, including clinical hints that aid in the recognition of this often-overlooked diagnosis. Differentiation of amitraz intoxication from the much more commonly seen pesticide-related organophosphate and carbamate intoxication is of utmost importance, in order to avoid erroneous, unnecessary, and often dangerous treatment.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
10/20. Lethal enterovirus-induced myocarditis and pancreatitis in a 4-month-old boy.After inconspicuous pregnancy and birth, a 16-year-old mother presented her male baby 5 days later with severe diarrhoea and vomiting. During the following weeks, the child temporarily showed hypotension, hypothermia and increased body temperature, bradyarrythmia with apnoea, continuing diarrhoea, sometimes vomiting and developed signs of pancreatic insufficiency. Due to increasing loss of weight and obviously severe dystrophia, parenteral nutrition had to be initiated. All clinical investigations revealed no underlying disease. Numerous biopsies, mainly from the gastrointestinal tract were taken, but no relevant pathological findings were disclosed. The baby was found lifeless by his mother, 4 months after birth. According to the death certificate, the physicians regarded the lethal outcome as a case of sudden infant death syndrome (SIDS). Histological and immunohistochemical investigations of organ samples revealed signs of myocarditis, pancreatitis and focal pneumonia. Molecularpathological techniques were used to detect enterovirus rna from tissue samples from the myocardium, liver and pancreas. Enteroviral myocarditis with concomitant pancreatitis was determined as cause of death.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
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