1/14. Use of midodrine (Gutron) to treat permanent hypotension in a chronic hemodialysis patient.Chronic hypotension, infrequent though possible in chronic renal failure patients on hemodialysis, has harmful consequences on their physical state and hence general well-being. These patients often experience acute intradialytic manifestations while non-pharmacologic interventions as pharmacologic agents are sometimes insufficient to improve symptoms. Well tolerated, midodrine appears to be a suitable and effective agent as it raises blood pressure significantly via its effect on peripheral alpha-adrenergic receptors. The authors describe their use of midodrine in a dialysis patient for the longest period of time reported up to now, documented by a pharmacokinetic study, confirming long-term both clinical efficacy and safety of the drug.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
2/14. Near-syncope after exercise.syncope and near-syncope are great diagnostic challenges in medicine. On the one hand, the symptom may result from a benign condition and pose little or no threat to health other than that related to falling. On the other hand, syncope or near-syncope can be the manifestation of a serious underlying condition that poses an imminent threat to life. patients with a cardiac cause of syncope are at far greater risk of dying in the first year after an episode of syncope or near-syncope than individuals with a noncardiac cause. A cardiac cause of syncope should be considered in every patient with syncope or near-syncope, but it is particularly common in older patients or in patients with known structural heart disease, arrhythmia, or certain electrocardiographic abnormalities. Although many diagnostic tests may be helpful in the evaluation of syncope and near-syncope, the history, physical examination, and electrocardiogram pinpoint the cause in many circumstances. syncope after exercise may be due to left ventricular outflow tract obstruction from aortic stenosis or hypertrophic obstructive cardiomyopathy but can also suggest the diagnosis of postexercise hypotension in which an abnormality in autonomic regulation of vascular tone or heart rate results in vasodilation or bradycardia after moderate-intensity aerobic activity. The patient discussed in this case highlights the importance of the clinical history in the evaluation of this condition, since the diagnosis was revealed as the patient's story was described and eventually acted out.- - - - - - - - - - ranking = 7.1392101099635keywords = physical examination, physical (Clic here for more details about this article) |
3/14. Hypotensive shock and angio-oedema from angiotensin ii receptor blocker: a class effect in spite of tripled tryptase values.In adverse reactions with shock, tripled tryptase values can support a diagnosis of anaphylaxis. A 51-year old physically fit woman experienced angio-oedema and hypotensive shock after irbesartan ingestion requiring noradrenaline infusion. serum tryptase rose to three times the normal value. Total immunoglobulin e and skin prick tests were normal, however. As nonallergic increases in tryptase have been observed, e.g. during angio-oedema from angiotensin-converting enzyme inhibitors, and bradykinin itself can degranulate mast cells acutely, we interpret the reaction as a class effect. To our knowledge, our report is one of the first on shock and angio-oedema from irbesartan.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
4/14. Treatment advice on the internet leads to a life-threatening adverse reaction: hypotension associated with niacin overdose.We describe a case of massive oral niacin overdose that resulted in severe persistent hypotension without the manifestation of cutaneous flushing. This case is the highest overdose of niacin reported in the literature to date and the first time severe persistent hypotension has been attributed to niacin. A 56-year-old male with a history of schizophrenia presented to the emergency department after orally ingesting 11,000 mg of niacin. The patient cited an internet resource that recommended high-dose niacin for therapy of schizophrenia as the reason for his ingestion. He stopped his psychiatric medications several weeks prior to his niacin overdose. At presentation, the patient was alert and normothermic. His pulse was 68 beats per minute and his blood pressure was initially 92/41 mmHg. hypotension with a blood pressure of 58/40 developed over the next few hours and persisted despite intravenous infusion of over 4 liters of normal saline. The physical exam was otherwise unremarkable, specifically without signs of an allergic reaction or cutaneous flushing. He required intravenous dopamine infusion for 12 hours to support a mean arterial blood pressure greater than 60 mmHg. Evaluation for other etiologies of hypotension was unrevealing. serum niacin levels were 8.2 ug/ mL and 5.6 ug/mL at 48 and 96 hours post ingestion, respectively, giving an apparent T1/2 of 87 hours. Massive overdose of niacin appears to be capable of causing severe, persistent hypotension in the absence of cutaneous flushing. In this case, the ingestion of a dietary supplement based on internet advice led to a severe adverse reaction.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
5/14. Indolent systemic mastocytosis as the cause of a long history of unexplained hypotensive episodes.Assessment of patients with unexplained hypotensive episodes in outpatient practice is often challenging, with an extensive differential diagnosis. The prevalence of systemic mast cell disease (MCD) is unknown, and the diagnosis is often elusive because serum and urine markers may become positive only after one of the self-limited, recurrent hypotensive episodes. Nevertheless, MCD is increasingly recognized as a cause of unexplained hypotension, secondary osteoporosis, and anaphylactic reactions to hymenoptera stings. We describe a 38-year-old man who had a 15-year history of undiagnosed, recurrent hypotensive episodes with stereotypic symptoms. Extensive evaluation during these years was unrevealing. On physical examination, he appeared to be a healthy man with a prominent macular rash. Results of skin biopsy showed tryptase-positive mast cells. He had markedly elevated serum tryptase levels, and results of bone marrow biopsy revealed 10% mast cells; all these findings were consistent with indolent systemic mastocytosis. Key features in his history and physical examination prompted the conclusive testing. The most telling features were hypotension, tachycardia, and the rash (urticaria pigmentosa).- - - - - - - - - - ranking = 14.278420219927keywords = physical examination, physical (Clic here for more details about this article) |
6/14. Case report: 30-yr-old female with exercise induced anaphylaxis.This case describes a 30-yr-old white female who presented with a 2-wk history of pruritic rash with exercise. This rash occurred with each bout of exercise and was accompanied by one episode of light-headedness. A bicycle ergometer exercise challenge resulted in a fine wheal and flare rash of the trunk and upper extremities that was associated with symptomatic hypotension. She was diagnosed with exercise induced anaphylaxis, and initial treatment with hydroxyzine was instituted. Side effects from the drug were poorly tolerated, and she was switched to inhaled cromolyn sodium. She had noted resolution of her symptoms while she took cromolyn as recommended. Two months after her initial presentation, she also began to experience the same rash with hot showers. exercise induced anaphylaxis is a well-described form of physical allergy that may be underdiagnosed. As the fitness boom continues and clinicians see more exercising patients, it will be important to recognize and understand this condition. It is a true anaphylactic reaction and, as such, certainly has the potential for significant morbidity and mortality.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
7/14. Man-in-the-barrel syndrome in a noncomatose patient: a case report.A 62-year-old man developed man-in-the-barrel syndrome (MIBS) after emergency four-vessel coronary artery bypass surgery. MIBS refers to the clinical syndrome of bilateral upper extremity paresis with intact motor functioning of the lower extremities, giving the appearance of being confined within a barrel. The pathogenesis of MIBS is believed to be cerebral hypoperfusion leading to border zone infarctions between the territories of the anterior and middle cerebral arteries. physical examination revealed bibrachial paresis, decreased upper extremity tone, mild left central VII palsy, flat affect, mild cognitive deficits, and poor balance while ambulating. An EMG showing poor motor unit recruitment and slow-firing motor units, and abnormal SSEPs indicated an upper motor neuron lesion. There was good progress in physical and occupational therapy, and good return of upper extremity function in four months. Only 11 cases of MIBS have been reported, all of whom were comatose; ten died. Our patient was never comatose and had good functional recovery.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
8/14. Neurally mediated syncope.The dominant feature of neurally mediated syncope (NMS) is loss of consciousness resulting from hypotension, alone or with bradycardia. The causes of NMS have been debated for sixty years and are still not fully understood; it is accepted that there may not be an identifiable physical or psychologic stressor that triggers NMS. Increased availability of certain procedures, such as head-up tilt study and long-term ambulatory event monitoring, provides an opportunity to diagnose NMS more accurately. A case study shows that effective treatment and control of syncope gives patients confidence and independence.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
9/14. Substance abuse: clinical identification and management.Substance abuse is a significant health problem in the adolescent population. Prevention is a formidable challenge, but attempts at discouraging experimentation in early adolescence and the promotion of healthy adult role models may be effective strategies. Questions that may elicit a history suggestive of abuse should be a routine part of the adolescent medical history. Pediatricians should be familiar with the important clinical findings resulting from intoxication with the various substances of abuse and should be able to recognize the "telltale" signs of abuse. Effective management is based on attention to the basics of life support, careful attention to the physical findings, and judicious use of specific therapeutic agents. Above all, a compassionate attitude should prevail if acute-phase recovery and long-term rehabilitation are to be successful.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
10/14. Ovarian cancer manifested as exertional hypotension due to obstruction of the inferior vena cava.We have reported a case of inferior vena cava obstruction caused by recurrent ovarian carcinoma. This case is noteworthy first because it shows that physical findings in inferior vena cava obstruction may be minimal. Secondly, we believe ours is the first reported case of exertional hypotension caused by obstruction of the inferior vena cava. Finally, ovarian cancer has rarely been reported as a cause of inferior vena cava obstruction.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
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