1/4. Severe transmyocardial ischemia in a patient with tension pneumothorax.OBJECTIVE: To report tension pneumothorax (TP) as a cause of severe myocardial ischemia. DESIGN: Clinical case report. SETTING: Medical intensive care unit of a university hospital. patients: One patient with severe shock attributable to right TP after unsuccessful percutaneous central venous catheterization. INTERVENTIONS: blood pressure, electrocardiogram (ECG), chest radiograph, and echocardiography during and after shock. MEASUREMENTS AND MAIN RESULTS: On admission the patient was in profound state of shock (heart rate 140 beats/min, blood pressure 65/30 mm Hg). Twelve-lead ECG showed pronounced ST segment elevation in leads II, III, aVF, and V4-V6. Chest radiograph revealed right TP with complete displacement of the mediastinum and the heart to the left side. Immediate right-sided tube thoracostomy resulted in reexpansion of the lung followed by instantaneous hemodynamic and respiratory improvement as well as nearly complete resolution of the ECG changes. Peak value of the creatine phosphokinase was 4140 U/L without significant elevation of the MB isoenzyme at any time. Moreover, the initial hypokinesia of the posterior and lateral left ventricular wall resolved completely, as demonstrated by echocardiography. CONCLUSION: The specific condition of TP may lead to impaired systolic and diastolic coronary artery blood flow affecting ventricular repolarization and T-wave configuration in ECG indicative of transmyocardial ischemia. General symptoms, namely hypotension, tachycardia, and hypoxemia, are likewise typical for cardiogenic shock attributable to myocardial infarction. Yet any therapeutic measure directed toward revascularization, such as thrombolysis or even percutaneous transluminal coronary angioplasty, would have had devastating consequences. Therefore, thorough physical examination of our patient was pivotal in disclosing the true origin of profound shock.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
2/4. Atypical presentation of shock from acute adrenal insufficiency in an adolescent male.OBJECTIVE: To report an atypical presentation of shock and acute adrenal insufficiency in an adolescent male. CASE SUMMARY: A 14-year-old boy with a history of nocturnal enuresis presented with a clinical picture suggestive of septic shock refractory to aggressive fluid and vasopressor management. history and physical examination were suggestive of shock secondary to an infectious etiology, associated with skin findings of hyperpigmentation. The laboratory studies were remarkable for normal sodium, potassium, glucose, as well as normal renin levels. hydrocortisone therapy led to improvement of his blood pressure and allowed weaning of vasopressor medications. Further laboratory studies, including adrenocorticotropic hormone stimulation test and adrenal antibodies, confirmed the diagnosis of primary adrenal insufficiency. CONCLUSION: Acute adrenal insufficiency is an uncommon cause of shock in the adolescent population. We report a clinical presentation suggestive of shock secondary to acute adrenal insufficiency remarkable for an atypical clinical and laboratory presentation. We further provide information on the management of acute adrenal crisis.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
3/4. 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 = 0.17300782448745keywords = physical (Clic here for more details about this article) |
4/4. adolescent female patient with shock unresponsive to usual resuscitative therapy.Thyroid storm (thyroid crisis) is a rare and serious complication of thyrotoxicosis with a significant mortality rate if left untreated. Early recognition of the syndrome with a thorough history and physical examination is therefore essential. The exact mechanism for this decompensation is unknown; however, many physiologic stressors can precipitate the crisis. This report describes an unusual case of a previously unrecognized thyrotoxicosis developing into a storm in a pediatric patient manifesting as refractory shock.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |