Infective endocarditis is a multisystem and potentially fatal disease. Systemic embolization is a relatively common complication, the spleen and central nervous system being the most frequent sites for septic emboli formation. Coronary artery septic embolization is extremely uncommon and its management remains controversial.We present the case of a 50-year-old male diagnosed with mitral valve infective endocarditis complicated with spleen and central nervous system embolization, who developed acute myocardial infarction two weeks after disease onset. The patient was successfully treated with combined mitral valve replacement and coronary artery bypass grafting.

Introduction: In December 2019, an outbreak of pneumonia caused by a novel coronavirus occurred in Wuhan, the capital of Central China’s Hubei Province and has been declared a public health emergency of international concern by the World Health Organization since January 2020.Material and Methods: A comprehensive search using the PubMed database was carried out to summarize the latest published information about the epidemiology, definition, pathogenesis, clinical characteristics, treatment options, prognosis and prevention of coronavirus disease 2019.Discussion: This new strain of coronavirus, named severe acute respiratory syndrome coronavirus 2, enters human cells that express angiotensin-converting enzyme II receptors, which exist in the respiratory, gastrointestinal and genitourinary tracts and heart, causing coronavirus disease. Transmission occurs essentially through the respiratory tract and the main symptoms are fever, cough and dyspnea. Diagnosis is based on epidemiological, clinical and imaging features and confirmed by nucleic acid testing.Conclusion: Despite intensive research, the exact origin of the virus and pathophysiology of coronavirus disease is not yet completely known, and clinically approved vaccines and drugs that target severe acute respiratory syndrome coronavirus 2 are lacking.

Wunderlich syndrome is a rare and possibly life-threatening haemorrhagic syndrome presenting as spontaneous nontraumatic renal rupture with subcapsular and perinephric haemorrhage. Apixaban, a direct oral anticoagulant recommended in patients with atrial fibrillation, has previously been associated with atraumatic solid organ rupture but, to date, no case of apixaban-related Wunderlich syndrome has been reported. We report a rare case of Wunderlich syndrome associated with apixaban while addressing the difficulties face by clinicians when managing anticoagulation in bleeding patients.

Breast cancer may metastasize to the lung, liver, bone, brain, and skin, with especially high rates of metastasis to skin sites.These skin metastases are called malignant wounds. Patients with malignant wounds often report multiple symptoms, and pain is one of the most common and distressing among them. Despite the availability of multiple guidelines about treatment to relieve pain, almost half of all cancer patients still receive inappropriate care for pain. A multidisciplinary approach can improve outcomes in terms of symptom control and quality of life and enable the detection of previously unmet needs of both patients and caregivers. Palliative care is a multidisciplinary therapy that aims to alleviate physical, psychological, and emotional suffering in patients at any stage of the disease. We present the case of a 53-year-old male with a three-year history of stage IV breast cancer. He was admitted to the internal medicine ward in July 2021 with uncontrolled pain related to a malignant wound in the left hemithorax. This was a case with physical, emotional, social, and existential factors contributing to severe pain, necessitating a multidisciplinary approach for adequate relief. Opioid titration and insomnia and anxiety treatment were initiated. Dressing care was applied with metronidazole impregnation and aminocaproic acid for hemorrhagic spots, followed by fat gauze. He was proposed to undergo antalgic radiotherapy, which was unfortunately associated with new onset of symptoms. Psychological support was provided for the patient and his family. We managed to control the pain and stabilize the wound; however, cachexia become evident with the disease progression. In the last week of his life, the patient still believed he would be able to undergo chemotherapy. He died in the emergency room, where he had gone to seek relief for uncontrolled symptoms. Even though the patient had an incurable disease associated with immense suffering since early 2019, he was only referred to the palliative care team during the last three months of his life. Existential suffering was an important dimension of this patient’s pain and was present until his death despite receiving psychological support. Late referral to palliative care is unfortunately frequent and often associated with poor quality of life and inability to plan or make end-of-life care decisions. Radiotherapy was proposed for pain control but was associated with serious side effects. In a palliative care setting, decision-making always needs careful consideration related to benefit versus harm and must involve the patient and his family. Living with stage IV cancer is an everyday challenge for patients, and clinicians may also find managing such patients very arduous and stressful. Symptoms must be actively studied and evaluated from a multidimensional perspective. Managing expectations throughout this process while maintaining hope is a delicate balancing act and should be undertaken by specialized palliative care teams.

IntroductionPain is prevalent in most pathologic situations that require healthcare and is very common in hospitalised patients. However, there is limited evidence about the prevalence and the actual management of pain in medical wards. The aim of this work was to evaluate and characterise pain management in an internal medicine ward. MethodsRetrospective analysis of clinical data of patients consecutively discharged from the internal medicine ward of a central tertiary hospital over a period of five months in 2018. Results199 patients evaluated, the median age was 78 years and 63% were female. Of these, 14% had a previous diagnosis of chronic pain, 24% were on chronic pain medication, and in 29% medication was interrupted. Pain was noted in medical records of 118 patients, with moderate to severe intensity in 67%. Among those, 71% had pain occurrence registered in the medical notes but not characterised in duration in 61%. The most common attributed etiologies of pain were musculoskeletal (16%), visceral (9%), and headache (8%); no identifiable cause was specified in 57%. In the group of patients reporting pain, 63% received analgesics. Opioids were used in 35% and 47% of patients with moderate and severe pain, respectively. At discharge, 12 patients were still referred pain, 16 had pain listed as a diagnosis, 45 were medicated for pain, and eight were referred for pain consultation. ConclusionsDespite being highly prevalent in the internal medicine ward, pain is still under-recognised, undervalued, and under-treated. Education of healthcare staff and adoption of treatment protocols is essential to improve care for these patients.