1/75. Cardiovascular toxicity after ingestion of "herbal ecstacy"."Herbal Ecstacy" (sic) is an alternative drug of abuse usually containing both ephedrine and caffeine. Our literature search did not reveal any other reported cases of cardiovascular toxicity related to herbal "drugs of abuse." A case of cardiovascular toxicity following the ingestion of herbal ecstacy is presented. A 21-year-old male presented to the emergency department with an initial blood pressure of 220/110 mmHg and ventricular dysrhythmias after ingesting four capsules of herbal ecstacy. He was treated with lidocaine and sodium nitroprusside, and his symptoms resolved in 9 h. The pathophysiology and clinical course of ephedrine toxicity are discussed. Emergency physicians should consider ephedrine preparations in the differential diagnosis of patients presenting with a sympathomimetic toxidrome. Drugs of abuse containing "herbal" products can produce serious morbidity and mortality.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/75. The incidental diagnosis.incidental findings transcend medical practice. Two cases are discussed in which significant conditions were discovered during clinical examination for an unrelated disorder. The first case presents a disease reported for the first time in a male. Recent literature has alluded to missed diagnoses found only at autopsies. With cost constraint as a national theme, the appropriate use of technology presents a challenge to the physician. The cases discussed raise questions about the process of diagnosis. Both situations bring to light the limitations of clinical investigation early in the pathologic process.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/75. Helping the hypertensive patient to help himself.The control of blood pressure in patients with hypertension is an important challenge in everyday medical practice. It can do much to reduce complications, but too often we fall short of our therapeutic goals. Much more can be done to help our patients help themselves if physicians, along with their paramedical staffs and their patients, make the effort. The results are gratifying in terms of motivation and successful long-term control of the blood pressure and the risks associated with hypertension. This paper outlines objectives and practical approaches to patient education and self-care of this common medical problem.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/75. Case 1: isolated systolic hypertension.Despite the prevalence of isolated systolic hypertension (ISH) in the elderly, many physicians are reluctant to treat the disorder. Recently identified as one of the major health challenges of the new millennium, ISH is the focus of this month's CME-accredited case study in hypertension, featured at www.CardiovascularEd. com.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
5/75. 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) |
6/75. mercury intoxication and arterial hypertension: report of two patients and review of the literature.Two children in the same household with symptomatic arterial hypertension simulating pheochromocytoma were found to be intoxicated with elemental mercury. The first child was a 4-year-old boy who presented with new-onset seizures, rash, and painful extremities, who was found to have a blood pressure of 171/123 mm Hg. An extensive investigation ensued. Elevated catecholamines were demonstrated in plasma and urine; studies did not confirm pheochromocytoma. mercury levels were elevated. These findings prompted an evaluation of the family. A foster sister had similar findings of rash and hypertension. Both had been exposed to elemental mercury in the home. The family was temporarily relocated and chelation therapy was started. A medline search for mercury intoxication with hypertension found 6 reports of patients ranging from 11 months to 17 years old. All patients showed symptoms of acrodynia. Because of the clinical presentation and the finding of elevated catecholamines, most of the patients were first studied for possible pheochromocytoma. Subsequently, elevated levels of mercury were found. Three children had contact with elemental mercury from a broken thermometer, 2 had played with metallic mercury and 1 had poorly protected occupational exposure. All responded to chelation therapy. Severe systemic arterial hypertension in infants and children is usually secondary to an underlying disease process. The most frequent causes of hypertension in this group include renal parenchymal disease, obstructive uropathy, and chronic pyelonephritis associated with reflux and renal artery stenosis. Less frequent causes include adrenal tumors, pheochromocytomas, neurofibromas, and a number of familial forms of hypertension. Other causes include therapeutic and recreational drugs, notably sympathomimetics and cocaine, and rarely, heavy metals. In children with severe hypertension and elevated catecholamines, the physician should consider mercury intoxication as well as pheochromocytoma. The health hazards of heavy metals need to be reinforced to the medical profession and the general public.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
7/75. The mind/body link in essential hypertension: time for a new paradigm.The origin of essential hypertension is believed by many to be at least partially emotion-related. A widely held paradigm is that perceived emotional distress raises blood pressure and leads eventually to sustained hypertension. However, decades of research have not provided strong or consistent support for this view. The purpose of this article is to briefly review this research, and to present a very different view of the mind-body link of hypertension. This view focuses on the role of emotions that are not consciously perceived, emotions that are unknowingly kept from conscious awareness, and largely ignored by patients, physicians and research. It suggests that the mind/body connection is often operative when we least suspect it. The evidence for this understanding, and the important implications regarding treatment of hypertension and other unexplained medical conditions with a suspected mind/body link, are discussed.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
8/75. hypertension in the young adult--come feel the pulse.hypertension occurring in teenagers and young adults is uncommon. Though the most common form is still essential hypertension, secondary causes are more commonly found here than in older adults. Renal, cardiovascular and endocrine diseases constitute most of these causes. Coarctation of the aorta is the most common cardiovascular cause of hypertension, and its importance lies in the fact that it is correctable, and that its persistence often leads to dangerous complications and early death. The cardinal sign of differential pulse and blood pressures between the upper and lower limbs can be detected clinically. Hence, the importance of a detailed physical examination in all young hypertensives, including palpation of all the pulses, cannot be overemphasized. We present 2 hypertensive young men who were found to have isolated coarctation of the aorta.The lesion in the first patient was located postductally just distal to the left subclavian artery.This area has been found to be the most common site of coarctation.The second patient had an unusual mid-thoracic coarctation. The clinical and radiological features as well as complications are highlighted. In young hypertensive patients, a high index of suspicion may enable the physician to make a timely diagnosis and hence avert the potentially disastrous complications that may arise in undetected cases.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
9/75. Applying evidence-based medicine to current practice: a round table panel discussion.Over the past decade, an expanding body of epidemiological and clinical trial data has been collated, culminating in the development of guidelines designed to help physicians make decisions about intervention and the intensity of treatment, based on objective assessments of the overall level of risk for cardiovascular disease. However, guidelines are not prescriptive and allow physicians leeway in interpretation. Thus, it is of clinical interest to explore some of the issues that may influence the use of these guidelines in clinical practice. This paper summarises a round table panel discussion that highlighted the usefulness of current guidelines, but also demonstrated that these guidelines, and the evaluation of cardiovascular risk, need to be used with care and always interpreted in the light of sound clinical judgement.- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |
10/75. warfarin therapy for an octogenarian who has atrial fibrillation.In north america, atrial fibrillation is associated with at least 75 000 ischemic strokes each year. Most of these strokes occur in patients older than 75 years of age. The high incidence of stroke in very elderly persons reflects the increasing prevalence of atrial fibrillation that occurs with advanced age, the high incidence of stroke in elderly patients, and the failure of physicians to prescribe antithrombotic therapy in most of these patients. This failure is related to the increased risk for major hemorrhage with advanced age, obfuscating the decision to institute stroke prophylaxis with antithrombotic therapy.This case-based review describes the risk and benefits of prescribing antithrombotic therapy for a hypothetical 80-year-old man who has atrial fibrillation and hypertension, and it offers practical advice on managing warfarin therapy. After concluding that the benefits of warfarin outweigh its risks in this patient, we describe how to initiate warfarin therapy cautiously and how to monitor and dose the drug. We then review five recent randomized, controlled trials that document the increased risk for stroke when an international normalized ratio (INR) of less than 2.0 is targeted among patients with atrial fibrillation. Next, we make the case that cardioversion is not needed for this asymptomatic patient with chronic atrial fibrillation. Instead, we choose to leave the patient in atrial fibrillation and to control his ventricular rate with atenolol. Later, when the INR increases to 4.9, we advocate withholding one dose of warfarin and repeating the INR test. Finally, when the patient develops dental pain, we review the analgesic agents that are safe to take with warfarin and explain why warfarin therapy does not have to be interrupted during a subsequent dental extraction.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
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