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Query: UMLS:C0022116 (ischemia)
 91,303 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

When faced with a patient with acute chest pain, clinicians must distinguish myocardial infarction (MI) from all other causes of acute chest pain. If MI is suspected, current therapeutic practice includes deciding whether to administer thrombolysis or primary percutaneous transluminal coronary angioplasty and whether to admit patients to a coronary care unit. The former decision is based on electrocardiographic (ECG) changes, including ST-segment elevation or left bundle-branch block, the latter on the likelihood of the patient's having unstable high-risk ischemia or MI without ECG changes. Despite advances in investigative modalities, a focused history and physical examination followed by an ECG remain the key tools for the diagnosis of MI. The most powerful features that increase the probability of MI, and their associated likelihood ratios (LRs), are new ST-segment elevation (LR range, 5.7-53.9); new Q wave (LR range, 5.3-24.8); chest pain radiating to both the left and right arm simultaneously (LR, 7.1); presence of a third heart sound (LR, 3.2); and hypotension (LR, 3.1). The most powerful features that decrease the probability of MI are a normal ECG result (LR range, 0.1-0.3), pleuritic chest pain (LR, 0.2), chest pain reproduced by palpation (LR range, 0.2-0.4), sharp or stabbing chest pain (LR, 0.3), and positional chest pain (LR, 0.3). Computer-derived algorithms that depend on clinical examination and ECG findings might improve the classification of patients according to the probability that an MI is causing their chest pain.
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PMID:The rational clinical examination. Is this patient having a myocardial infarction? 1005 39

Pulmonary embolism is the fourth leading cause of pleural effusion. The possibility of pulmonary embolus should be evaluated for all patients who have undiagnosed pleural effusion. The mechanism of pleural effusion caused by pulmonary embolus is usually increased interstitial fluid in the lungs as a result of ischemia or the release of vasoactive cytokines. Approximately 75% of patients with pulmonary emboli and pleural effusion have pleuritic chest pain. The most common cause of pleuritic chest pain and pleural effusion in patients under 40 years old is pulmonary emboli. Pleural effusion resulting from a pulmonary embolus usually occupies less than one-third of the hemithorax. Dyspnea is frequently out of proportion to the size of the pleural effusion. Pleural fluid caused by pulmonary emboli is usually exudative but is occasionally transudative. d-Dimer testing is a good screen for pulmonary emboli. If d-dimer results are positive, then a spiral computed tomograph should be obtained to confirm the diagnosis. Low-molecular-weight-heparin has become the initial treatment of choice for patients with pulmonary emboli and pleural effusion.
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PMID:Pleural effusion due to pulmonary emboli. 1147 Sep 74

Clozapine has been shown to be the most efficacious therapy for treatment resistant schizophrenia, estimated at one third of all schizophrenia cases. There is significant morbidity and mortality associated with clozapine including risk of agranulocytosis, aspiration pneumonia, bowel ischemia, myocarditis, seizures, and weight gain. Here we present a case of a 62-year-old man with chronic paranoid schizophrenia refractory to numerous antipsychotics who was started on clozapine therapy during an acute inpatient psychiatric admission. Within three weeks of starting clozapine, the patient developed flu-like symptoms, pleuritic chest pain, and was sent to a medical hospital for evaluation. After transfer, the patient had a rapidly deteriorating course with newly developed congestive heart failure, acute respiratory failure requiring intubation, and cardiovascular collapse requiring vasopressors. The patient expired within two days of transfer and four days after initial symptoms developed. The underlying etiology in this case is likely clozapine induced myocarditis leading to rapid cardiovascular collapse and death. Mortality with clozapine induced myocarditis has been estimated up to 24%. Given that 90% of clozapine cardiotoxic sequelae are seen in the first month post-initiation, more rigorous post-initiation surveillance is recommended for the first four weeks of clozapine with weekly cardiac enzymes (troponins, creatinine kinase-MB), EKG, and acute inflammatory markers (C-reactive protein, and erythrocyte sedimentation rate).
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PMID:Potentially fatal outcomes associated with clozapine. 2950 32

The purpose of this case presentation is to discuss right upper quadrant pain as an atypical presenting symptom in pulmonary infarction and review the typical computed tomography (CT) imaging features of pulmonary infarction to improve diagnostic accuracy. Pulmonary infarction results from occlusion of distal arterial vasculature within the lung parenchyma leading to ischemia, hemorrhage, and ultimately necrosis. Patients with lung infarction typically present with pleuritic chest pain and may have associated signs or symptoms of pulmonary thromboembolism or deep vein thrombosis. In this case study, a 34-yr-old female devoid of any symptoms indicative of either pulmonary embolism or deep vein thrombosis presented with right upper quadrant pain 1 mo status post open reduction internal fixation for a left ankle fracture. Multiple clinic visits spanning approximately 7 d were significant for a right lower lobe opacity seen on CT of the abdomen which was presumed to represent community acquired pneumonia as a source for the patient's RUQ pain. The patient presented to the emergency department 1 wk later (6 wk following her initial surgery) complaining of left lower extremity swelling and was subsequently diagnosed with a left lower extremity DVT via ultrasound. CT of the pulmonary arteries was negative for PE but identified a right lower lobe opacity which in retrospect was consistent with pulmonary infarction.
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PMID:Pulmonary Infarction: Right Upper Quadrant Pain as a Presenting Symptom With Review of Typical Computed Tomography Imaging Features. 2988 60