Sudden Onset Of Dyspnea Research Articles

Two-edged Knife: Massive Pulmonary Embolism and Thrombolytic Contraindication

İntroduction:
 Pulmonary embolism is a common cause of death among emergency department admissions, and it has a high mortality and morbidity rate. Etiological reasons are generally associated with immobility. Radiological imaging methods are at the forefront in diagnosis. Anticoagulant and thrombolytic therapy may be preferred in treatment according to the hemodynamic condition of the patient.
 
 Case report:
 A 56-year-old female patient admitted to the emergency department with sudden onset of dyspnea and syncope with a condition of cardiogenic shock, and echocardiography revealed an enlargement of the right heart chambers and impaired functions, and a tomography was performed with the pre-diagnosis of pulmonary embolism. When systemic thrombolytic therapy was contraindicated in the patient who had embolism on tomography, catheter-based thrombectomy and selective low-dose thrombolytic therapy to the pulmonary artery were administered. The patient, who became hemodynamically stable and his shock condition improved, was discharged with anticoagulant therapy.
 
 Conclusion:
 When left untreated, pulmonary embolism is a disease with a high mortality rate. Although systemic thrombolytic treatments are contraindicated in some patients, successful results can be obtained with locally effective interventional treatments in these patient groups.
 
 Keywords: Pulmonary embolism, catheter-based thrombolysis, thrombolytic therapy

Thoracoscopic hilar lung lobectomy in two dogs

This report aimed to describe the surgical procedure and outcome of thoracoscopic hilar lung lobectomy in two dogs with a solitary pulmonary emphysema. Both patients were positioned in left lateral...

PRIMARY SPONTANEOUS PNEUMOTHORAX IN A YOUNG HEALTHY MALE SECONDARY TO WEIGHT LIFTING: A CASE REPORT AND REVIEW OF THE LITERATURE

SESSION TITLE: Medical Student/Resident Disorders of the Pleura Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: A primary spontaneous pneumothorax (PSP) is defined as a pneumothorax that occurs without clinically apparent underlying lung disease. Though the etiology of PSP remains a subject of debate, several risk factors have been identified, including tobacco use, male sex, low body mass index, and height [1]. PSP is also infrequently reported secondary to athletic activity, with 10-20% of cases due to heavy exertion, such as running [2]. However, PSP has rarely been reported secondary to weightlifting, with fewer than 5 cases previously known to be published. Here we present a case of PSP secondary to weightlifting in a young healthy male without known risk factors. CASE PRESENTATION: A 30 year-old male active duty member of the Air Force presented to the emergency department with sudden-onset dyspnea and pleuritic chest pain that occurred during a Valsalva maneuver while bench pressing approximately 80 kilograms. Vital signs were within normal limits upon arrival to the emergency department. Plain films of the chest revealed a left apical primary spontaneous pneumothorax with an apical-pleural distance of 7.7 cm. The patient was placed on oxygen, and an 8 French chest tube was placed, which remained on a Heimlich valve overnight. Computed tomography (CT) scan of the chest without contrast obtained the day after presentation demonstrated near-complete resolution of the pneumothorax without evidence of peripheral pleural blebs. When he presented for follow up one month later, he remained asymptomatic and a repeat plain film did not demonstrate pneumothorax recurrence. The patient denied history of smoking, significant medical history, recent high altitude flying, or any other known risk factors for spontaneous pneumothorax. DISCUSSION: Despite decades of study, the disease process remains poorly understood. Proposed mechanisms include emphysema-like changes leading to rupture of subpleural blebs and absence of mesothelial cells leading diffuse “pleural porosity” leading to slow leak of air [3]. The mechanism of weightlifting-induced pneumothorax is equally unclear, but is theoretically due to increased intrathoracic pressure with long breath holds during Valsalva, as has previously been described in cannabis users. Weightlifting is rarely described as an etiology for PSP, but characterization of this etiology could be important in management, as treatment often differs depending on risk of recurrence. More research is needed to examine specific phenotypes and mechanisms of PSP in order to appropriately tailor management. CONCLUSIONS: Primary spontaneous pneumothorax has been associated with heavy exertion and rarely with weightlifting, but further research is needed to examine this phenotype to tailor treatment based on recurrence risk. Reference #1: Sahn S.A., Heffner J.E. Spontaneous pneumothorax. N Engl J Med 2000;342:868-74. Reference #2: Simoneaux S.F., Murphy B.J., Tehranzadeh J. Spontaneous pneumothorax in a weight lifter: a case report. Am J Sports Med: 1990;18(6):647-48. Reference #3: Grundy S, Bentley A, Tschopp J. Primary spontaneous pneumothorax: a diffuse disease of the pleura. Respiration: 2012;83(3);185-89. DISCLOSURES: No relevant relationships by John Hunninghake, source=Web Response No relevant relationships by Lauren Sattler, source=Web Response

Leg massage during pregnancy with unrecognized deep vein thrombosis could be life threatening: a case report

BackgroundTraditional massage seems to be safe but not entirely risk free, though serious adverse events are very rare. This report is aimed at illustrating a rare but fatal presentation of massive pulmonary embolism caused by leg massage and also to encourage both massage providers and pregnant women to be aware of undetected or subtle deep vein thrombosis, which could be a life threatening condition as a consequence of leg massage.Case presentationA 25-year-old primigravid Thai woman underwent massage at a traditional massage shop at 25th week of gestation. Shortly after leg and foot massage, she had a sudden onset of dyspnea, followed by consciousness alteration, brief spastic-like convulsion, became unconscious and suffered a cardiac arrest. Basic life support (BLS) at the event scene as well as during transfer and advanced cardiovascular life support (ACLS) at the hospital were provided, resulting in successful resuscitation but persistent coma. Bedside echocardiography showed poor contractility of the dilated right ventricle, and pulmonary embolism was suspected. CT angiography (CTA) revealed multiple concentric intraluminal filling defects within the right and left pulmonary arteries, indicating massive pulmonary embolism. The fetus died in utero and spontaneous labor and vaginal delivery occurred.ConclusionLeg massage in patients with deep vein thrombosis can dislodge thrombi, leading to life threatening pulmonary embolism, and should be contraindicated. Since pregnant women are at a higher risk of undetected or subtle thromboembolism, traditional massage in pregnant women should be contraindicated unless they are proven to have no such risk.

Pulmonary embolism: A brief review

Pulmonary embolism (PE) is characterized as pulmonary artery obstruction caused by a thrombotic embolus the usual clinical presence of acute PE involves a patient with a sudden onset of dyspnea and pleuritic chest pain at breathing, while blood coughing (hemoptysis), signs of deep vein thrombosis (DVT) and even collapse are less prevalent. PE is classified as PE which is massive, sub-massive and low risk. PE is a significant cause of morbidity and mortality among the patients who are hospitalized. When venous clot is dislodged from the place where it was actually formed, the clot then proceeds towards a vessel of pulmonary circulation leading to pulmonary embolism. Many factors affect pulmonary embolism such as prolonged immobility, advanced age, postoperative time, post-infarction period, heart failure, obesity, pregnancy, etc. Treatment mainly involves anti- coagulants. This brief review summarizes the pathophysiology, risk factors and treatment, management and supportive measures involved in Pulmonary embolism. Keywords: Pulmonary Embolism, Deep vein thrombosis, Bronchospasm, Thromboembolism.

Acute inhalation injury after marijuana use: A hidden cause

Marijuana is one of the most extensively smoking substance all around the world, although not common in our society. Its effects on lung are similar to tobacco, causing increased cough, sputum, hyperinflation, and rapid bronchodilatation following with possible airway obstruction. Chronic usage of marijuana may cause a variety of conditions such as bronchitis, large bullae formation, and pneumonia. Here, we report an uncommon case of hidden marijuana smoking causing acute inhalation injury. A 39-year-old male had consulted clinics with sudden onset of dyspnea, cough, and nausea. His chest X-ray and thorax computed tomography have revealed peripheral opacities with ground-glass infiltrations. After a detailed review of history, he was diagnosed with acute inhalation injury due to hidden marijuana smoking. As a conclusion, clinicians who encounter with individuals who have concurrent inhalation damage need to take a careful exposure history and should be alert for the possibilities of further complications and a worsening clinical picture.

Primary Mediastinal Malignant Mixed (Non-seminomatous) Germ Cell Tumor Presenting as Superior Vena Cava Syndrome

Abstract Introduction Mediastinal germ cell tumors are commonly seen in children and young adults with male preponderance. They are clinically classified as teratomas, seminomas and nonseminomatous germ cell tumors. Primary mediastinal mixed germ cell tumor falls under the nonseminomatous classification and are very rare. These patients have poor prognoses despite multidimensional strategic approach (chemotherapy, radiotherapy, surgical intervention). Case Discussion A previously well 27-year old male initially presenting with non-productive cough and a right anterior neck mass unresponsive to antibiotic therapy is subsequently diagnosed to be an extra-gonadal germ cell tumor of the anterior mediastinum. Two months through the course of disease, patient’s symptoms have progressed presenting with facial edema, engorged neck veins and cardio-respiratory distress. He is later found to be admitted in the intensive care unit where further work-ups led to the diagnosis of primary mediastinal mixed (non-seminomatous) germ cell tumor. Chemotherapy (cisplatin, bleomycin, etoposide - 1 cycle) and chest radiotherapy (4 sessions) were initiated causing resolution of symptoms. One week after discharge, patient presented with seizures and sudden onset of dyspnea. Patient was brought to the emergency room where he subsequently expired. Discussion This case report presents an account of this rare disease entity from its initial presentation to post-mortem analysis. Primary mediastinal germ cell tumors are rare with a poor prognosis and should be strongly considered in the diagnosis of young men with a mediastinal mass and superior vena cava syndrome.

ACUTE MITRAL REGURGITATION DUE TO RUPTURED LEAFLET CAUSING ASYMMETRICAL UPPER LOBE PULMONARY EDEMA

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Cardiogenic unilateral pulmonary edema (UPE) is a rare clinical entity that is often misdiagnosed initially. Most cases of cardiogenic edema occur in the right upper lobe and are caused by severe mitral regurgitation (MR). CASE PRESENTATION: An 82 year old male with diastolic heart failure, mitral regurgitation, atrial fibrillation, sick sinus syndrome, and chronic bronchiectasis presented with acute onset severe dyspnea without fever. He was discharged 12 hours prior from an outside hospital admission for recurrent multilobar pseudomonas pneumonia. He was euvolemic on exam, and chest X-ray showed bilateral upper lobe opacities consistent with outside CT scan. The patient was immediately placed on BiPAP for respiratory support and started empirically on ceftazidime/avibactam for possible pneumonia. Despite broad spectrum treatment his respiratory status acutely worsened and he was noted to have a new loud harsh systolic murmur. Repeat CXR showed new confluent edema in the right upper lung. Immediate transthoracic echocardiogram revealed rupture of the posterior mitral leaflet chordae secondary to degenerative changes. The patient was considered for urgent transfer to tertiary center for surgical repair of the mitral valve. Unfortunately, the patient’s status declined rapidly with a cardiogenic picture and end-organ failure. On hospital day 4 care was withdrawn and he passed away. DISCUSSION: The association of unilateral pulmonary infiltrates with leukocytosis and acute respiratory distress often leads to antibiotic therapy. A history of sudden onset dyspnea, organic murmur and elevated B-natriuretic peptide levels in the absence of fever may help differentiate upper lobe edema from other diagnoses. Furthermore, patients with UPE have a higher mortality than patient with bilateral pulmonary edema, and delay in adequate treatment may be contributory. It is studied that retrograde flow of blood directed across the left atrium toward the orifices of the right upper lobe pulmonary veins in severe MR results in a focal increase in the pulmonary venous pressure. Echocardiography is useful in determining the severity of MR and its cause. In this case, symptoms were initially attributed to pneumonia, but we later became suspicious of cardiogenic UPE based on new unilateral pulmonary infiltrate on CXR with new onset murmur. Indeed, ruptured chordae of the posterior leaflet in the setting of severe MR was confirmed on echocardiogram. CONCLUSIONS: Cardiogenic UPE can easily be mistaken for pneumonia or other pulmonary pathology. It is important to re-consider the differential diagnosis in sudden development of asymmetrical pulmonary infiltrate in a patient, taking into account physical examination findings and the clinical course. Upper lobe pulmonary edema could be a sign of severe mitral regurgitation that needs to be promptly recognized to avoid delays in life-saving intervention. Reference #1: Legriel S, Tremey B, Mentec H. Unilateral pulmonary edema related to massive mitral insufficiency. Am J Emerg Med. 2006;24:372. Reference #2: Handagala, R., Ralapanawa, U. & Jayalath. Unilateral pulmonary edema: a case report and review of the literature. T. J Med Case Reports. 2018; 12: 219. DISCLOSURES: no disclosure on file for Michael Casey; No relevant relationships by Janice Lee, source=Web Response No relevant relationships by Tanuja Yalamarti, source=Web Response

Expecting the unexpected.

e14066 Background: Myasthenia gravis is an autoimmune neuro-muscular disorder traditionally seen in bi-modal distribution in young women or older men. Discovery of immunotherapy has brought hope in survival outcomes for patients with malignant melanoma, lung, renal and head/neck cancers but it also opens Pandora’s box of immune-related toxicities for which early recognition and appropriate clinical management are paramount. Here we describe a case of immunotherapy induced myasthenia gravis de novo. Methods: A 77-year-old man with HPV+ stage IVA squamous cell carcinoma of the tongue presented with sudden onset orthopnea and dyspnea on exertion for the past day. One week ago, he received his second cycle of nivolumab as part of his neoadjuvant therapy. He was seen at an outside hospital and was found to be acute hypercapnic respiratory failure and placed on BiPAP. He was started on antibiotics for community-acquired pneumonia with levofloxacin and doxycycline and transferred to a tertiary care center for further management. On further evaluation, he endorsed diplopia, blurry vision, fluctuating muscle weakness that is worse at the end of the day, change in voice and proximal muscle weakness. His exam was consistent with bilateral ptosis, weak hip flexion and shoulder abduction, positive sniff test and poor vital capacity and negative inspiratory force values suggestive of impending respiratory and diaphragmatic failure secondary to myasthenic crisis. He was admitted to the ICU and placed on BiPAP and frequent NIF and VC monitoring. He was started on pyridostigmine but showed no clinical improvement on day 1 and hence was initiated on plasmapheresis from day 2 for a total of 10 days. Results: Investigations showed positivity of Ach-R modulating and binding and blocking antibodies with negative voltage gated calcium channel antibodies. EMG revealed decrement of the compound muscle action potential in the repetitive stimulation test indicative of myasthenia gravis. He responded well to the above treatment and underwent successful left partial glossectomy and weaned off mechanical ventilation and has been cancer free so far. He is doing well on maintenance prednisone and pyridostigmine. Conclusions: There is a significant 30.4% MG-specific-related mortality due to immunotherapy alone which this case demonstrates the importance of vigilance and early detection for effective treatment and management. It highlights need for the oncological world and our colleagues in various other disciplines of healthcare to identify and mitigate the effects of immunotherapy which has become our hope in beating cancer.

Awareness during CPR on cardiac arrest due to aortic dissection

Awareness during CPR is formerly reported in the literature but only in rare cases and it is still not clear whether these cases have anything in common.
 A case report regarding a 69-year old male patient.
 The patient was admitted to the hospital due to 3 days dyspeptic symptoms and sudden onset of dyspnoea a few hours before arriva. During admission a short period of tachycardia (250/min) is followed by asystolic cardiac arrest. CPR is immediately initiated. By the arrival of the cardio-resuscitation-team, the patient has a peripheral hemoglobin saturation of 100% and a high level of awareness with open eyes and movement of the head and both arms and legs. Re-evaluation of the hearts rhythm after 3 minutes still shows asystoli. A total of 10 mg of Epinephrine is administered in boluses of 1 mg every 3-5 minutes. By the 3ed hand-off for rhythm evaluation, the patient is orally intubated. A total of 5 arterial gas samples are done during the 90 minute CPR, and despite a decrease in pH to 7,11 and lactate of 18 after 90 minutes all other markers remain within the normal range, and both the arterial and peripheral hemoglobin saturation remains 100%. The level of awareness does not decrease notably during the 90 minutes. Echocardiography shows a heart with no noticeable ultrasonic movement. A projection visualizing the aortic arch raises suspicion of an aortic dissection. The autopsy shows he has have suffered a complete aortic dissection
 High level of awareness plus saturation and arterial gas almost within the normal range through all 90 minutes indicate very effective chest compressions and peripheral and cerebral blood flow. Even though the patient had a poor prognosis (complete aortic dissection and refractory asystole), termination of CPR raised ethical questions in the team as the patient was still conscious once the resuscitation was terminated by 90 minutes. Awareness during CPR also raises the question of proper sedation doing resuscitation, which is currently not part of the guidelines. Further research regarding pain relief during CPR as well as increased focus on communicative and ethical aspects during CPR is needed.

Bicalutamide-induced Eosinophilic Pneumonitis - A Serendipitous Diagnosis

Bicalutamide is a first-generation non-steroidal anti-androgen. Interstitial lung disease is a rare side effect of bicalutamide. Centres in the United States of America and Japan have previously reported bicalutamide-induced interstitial lung disease. This has not been reported in the United Kingdom.
 An 86-year-old Caucasian man with a history of advanced prostate cancer, on oral bicalutamide, presented to the emergency department with sudden onset dyspnoea and chest tightness.
 Bicalutamide-induced eosinophilic pneumonitis co-existing with community acquired pneumonia, and left ventricular systolic dysfunction were suspected, based on physical examination findings and investigation results that include blood tests, chest radiographs, echocardiogram, in addition to computed tomography pulmonary angiogram performed to rule out pulmonary embolism.
 There was a marked clinical, biochemical and radiological improvements after discontinuation of bicalutamide, initiation of a high-dose steroid, intravenous antibiotics, and diuretic. Prostate cancer retains a high incidence in the Western population. Recognising toxicities due to anti-androgen therapies is relevant to clinical practice.

Repeated Thrombolytic Treatment for Recurrent Pulmonary Thromboembolism: A Report of 2 Cases and a Literature Review.

We present 2 cases of pulmonary thromboembolism (PTE). The first case, a 50-year-old man, was admitted to the emergency department because of sudden onset dyspnea and left side chest pain. He was diagnosed with intermediate-risk (submassive) PTE, and thrombolytic treatment was commenced. The patient fully recovered, but 5 days later, he was diagnosed with a new, high-risk PTE. The second patient, a 23-year-old woman, presented with syncope, dyspnea, and chest pain for 2 days. She was diagnosed with high-risk (massive) PTE. Thrombolytic treatment was commenced, and the patient fully recovered, too. But the later patient was also diagnosed with a new PTE 4 days later. We applied repeated thrombolytic treatment in the patients due to repeated PTE. The first patient fully recovered and was discharged from the hospital, but the second patient died because of gastrointestinal bleeding and renal insufficiency. A repeated thrombolytic treatment could be an alternative treatment for these patients, considering treatment's risks.

An atypical case of pulmonary embolism from a jugular vein

SummaryNeck venous malformations and their potentially life-threatening complications are rarely reported in the available literature. Cases of aneurysmal or hypo-plastic jugular vein thrombosis associated with systemic embolization have not been frequently reported. We present the case of a 60-year-old male, without any known risk factors for thromboembolic disease, admitted for sudden onset dyspnea. The physical examination was remarkable for a right lateral cervical mass, expanding with Valsalva maneuver. Thoracic CT with contrast established the diagnosis of bilateral pulmonary embolism and raised the suspicion of superior vena cava and right atrial thrombosis. Bedside transthoracic echocardiography confirmed the presence of a large right atrial thrombus, with intermittent protrusion through the tricuspid valve. Systemic thrombolysis with Alteplase was initiated shortly after diagnosis, in parallel with unfractionated heparin, with complete resolution of the intracavitary thrombus documented by echocardiography. The patient showed significant improvement in symptoms and was later started on oral anticoagulation. Computed vascular tomography of the neck was performed before discharge, showing hypoplasia of the left internal jugular vein and aneurismal dilation of the contralateral internal jugular vein, without thrombosis. There were no identifiable systemic causes for thrombosis. Surgical resection of the aneurismal jugular vein was excluded, because of its potential to cause intracranial hypertension. The preferred therapeutic option in this case was long-term oral anticoagulation.

GASTROESOPHAGEAL REFLUX (GERD): A MAJOR FACTOR IN HIGHLY LABILE STEROID-DEPENDENT ASTHMA

Introduction In the setting of severe asthma with difficult to control symptoms, it is crucial to evaluate for other diagnoses and comorbidities in order to optimize management. In the case presented, sub-optimally treated GERD was identified as the driving force causing severe asthma symptoms. Case Description A 13-year-old female was evaluated for systemic steroid-dependent asthma. She reported frequent sudden-onset nocturnal dyspnea that was partially responsive to bronchodilators. She had one ICU admission and two near-syncopal events due to severe respiratory distress in the past year. Episodes persisted despite taking 2 mg/kg of prednisone, daily. Bronchoscopy and high-resolution chest CT were unremarkable. A 24-hour pH / impedance probe study identified excessive acid and nonacid reflux reaching the proximal portion of the esophagus and pooling of fluid in the esophagus. High-dose proton pump inhibitor therapy was initiated, and prednisone was tapered without worsening of her asthma. Discussion As in the case presented, ongoing reflux can manifest as highly labile difficult to control asthma even in the absence of typical reflux symptoms. It is important to consider an impedance study to assess for ongoing GERD in patients with difficult to control asthma. If present, optimizing GERD management with acid suppression therapy and, in some cases, surgically with fundoplication, may be necessary to control severe asthma symptoms.

Pulmonary Thromboembolism in Behcet’s Disease: A Case Report

Behcet’s disease is a vasculitis which presents as recurrent oral and genital aphthous ulceration, uveitis and skin lesions. Unlike other types of vasculitis, venous system involvement is a common manifestation of Behcet’s disease. Despite the high incidence of deep vein thrombosis in Behcet’s disease, pulmonary artery thromboembolism (PTE) is a rare complication. In this article, we report on a 44-year old man who experienced recurring painful oral ulcers, bilateral panuveitis, superficial phlebitis and positive pathergy which had led to a diagnosis of Behcet’s disease 12 years earlier. He developed sudden onset dyspnea, pleuritic chest pain and hemoptysis two days before admission. The patient had tachypnea and mild respiratory distress at the time of admission. CT angiography showed filling defects in the inter-lobar arteries of both lungs with sub-segmental consolidation. A lung perfusion scan showed multiple segmental and sub-segmental perfusion defects in both lungs which did not match the ventilation scan. A diagnosis of PTE was made and anticoagulation with enoxaparin and warfarin was begun. The tachypnea, chest pain and hemoptysis disappeared after three days and he was discharged after 10 days with warfarin. His disease was in complete remission at eight months after discharge.

Trombofilia hereditária: um caso, várias questões

Introduction: Over 50% of cases of hereditary thrombophilia are associated with the either the G20210A prothrombin gene mutation or factor V Leiden. The prothrombin G20210A mutation is present in 0.7-4% of the general population and triples the risk of thromboembolism. The role of this mutation in the recurrence of the condition is unclear. Women with this mutation have an increased risk of thrombotic events during pregnancy and with oral contraceptives. The aim of this report is to raise awareness of the factors that contributed to thromboembolism in a young woman and to discuss the implications for the individual and the family. Case description: A 25-year-old female in a nuclear family at stage I of the Duvall cycle, without a family history of embolism, developed a pulmonary thromboembolism (PT) after receiving a combined oral contraceptive. The G20210A prothrombin gene heterozygous mutation was identified. She was put on anticoagulant therapy for six months. One year ago she expressed a desire to conceive and was referred for preconception counseling at a local hospital. She was advised to return to hospital in case of pregnancy. Following confirmation of pregnancy by her family doctor at the end of January 2015, the patient was immediately referred to the hospital for a high-risk pregnancy consultation. In February she was admitted to the emergency department with the sudden onset of dyspnea and was diagnosed with a PT. Enoxaparin therapy was started and continued postpartum. There were no other complications and a healthy baby was delivered at 40 weeks of gestation by a normal delivery. The patient has a 22-year-old sister who is considering starting contraception. Comment: This case highlights the importance of starting low molecular weight heparin treatment in early pregnancy in women with this mutation. It also stresses the importance of screening for the mutation in asymptomatic relatives.

Triple POCUS: A New Approach to an Old Problem.

Pulmonary embolism (PE) is the most serious and life-threatening clinical presentation of venous thromboembolism, and difficult to diagnose. Triple point-of-care-ultrasonography (POCUS) of the lung, heart and leg veins is a multiorgan approach that may help to evaluate patients suspected of having PE, in combination with existing protocols and computed tomographic pulmonary angiography (CTPA). We present the case of a 26-year-old man with sudden onset of dyspnoea and swelling of the leg with a Well’s score of 9. With CTPA unavailable at the time of presentation, triple POCUS showed subpleural consolidations and a venous thrombus in a popliteal vein. A diagnosis of deep vein thrombosis with PE was made and the appropriate treatment was started immediately. Although triple POCUS has less sensitivity and specificity than CTPA, it could be very useful in some clinical settings.LEARNING POINTSIn a patient with suspected pulmonary embolism, the best diagnostic strategy is to combine clinical assessment, plasma D-dimer measurement and computed tomographic pulmonary angiography (CTPA).Triple point-of-care ultrasonography of the lung, heart and leg veins may improve clinical assessment of pulmonary embolism if CTPA is unavailable or contraindicated.Point-of-care ultrasonography should be incorporated as the fifth pillar of the physical examination.

Hypocalcaemia (puerperal tetany, milk fever, eclampsia) in a ferret (Mustela putorius furo)

Dyspnoea and/or collapse are not uncommon presenting signs for ferrets (Mustela putorius furo) brought in to the veterinary clinic. A 2-year-old female entire ferret was presented 3 weeks post-whelping with sudden onset collapse and dyspnoea. Blood glucose levels were found to be normal, however biochemistry analysis showed profound hypocalcaemia. Clinical signs resolved fully after the administration of calcium gluconate. This case report alerts the clinician to the clinical presentation and management of hypocalcaemia in the lactating ferret.

Atrial Myxoma? But it’s not

Postpartum period carries high risk of pulmonary embolism due to hypercoagulability state. Pulmonary embolism (PE) should be suspected in postpartum patient who has short history of progressing right heart failure without underlying heart disease. We report a case of pulmonary embolism with large right atrial thrombus without deep vein thrombosis in a 27 years old lady, para 1+2,post-delivery day 30 who presented with sudden onset of dyspnea and giddiness. She was diagnosed with right atrial thrombus complicated by acute pulmonary embolism. An emergency operation was performed and intraoperatively a pedunculated mobile mass is attached to the right atrial wall mimicking atrial myxoma, with incidental finding of patent foramen ovale. The mass was removed and concomitant pulmonary embolectomy was performed. The postoperative course was uneventful with the patient subsequently discharged.International Journal of Human and Health Sciences Vol. 02 No. 03 July’18. Page : 155-157

Case Study: Traumatic Pneumothorax after Parachute Landing

Introduction: Pneumothorax during military airborne operations is an uncommon injury among paratroopers. More common injuries are fractures or sprains to the lower extremities, as this is where most of the impact is absorbed during parachute landings. Classically, a pneumothorax will present with sudden onset severe chest pain and dyspnea warranting immediate medical evaluation. Among military service members, pneumothorax is more likely to occur because of traumatic injuries such as from motor vehicle accidents. Case presentation: This case highlights an otherwise healthy male paratrooper, who presented 24 hours following routine airborne training. Conclusion: Symptoms of even mild dyspnea or chest pain in military paratroopers following airborne operations should prompt immediate evaluation for pneumothorax.