The coronavirus pandemic has resulted in profound changes in healthcare delivery, some based on official reforms and others driven by healthcare professionals’ fear of exposure to coronavirus disease (COVID-19). Many patients require screening tests of one form or the other before being attended to in hospitals. The protean clinical manifestations of this highly transmissible infection require that a high index of suspicion be maintained. Pulmonary embolism is a potentially fatal emergency whose presentation is mimicked by COVID-19. Delays in ruling out COVID-19 may result in undue delays in initiating treatment for pulmonary embolism, potentially resulting in significant morbidity and mortality. This article presents a patient whose treatment for acute pulmonary embolism was forestalled by delays in getting the polymerase chain reaction test for COVID-19 done. It reiterates the need for physicians to test promptly in order to allow early focus on differential diagnoses which were routinely being investigated promptly prior to the COVID-19 pandemic.
Cardiovascular symptoms like chest pain and palpitations are among the commonest reasons for outpatient hospital visits. Physician preoccupation with ruling out sinister cardiological diagnoses often results in a failure to recognise mental health-related disorders, which account for over 40% of such cases, especially among young women. These disorders can independently cause cardiovascular symptoms or worsen preexisting cardiovascular disease, worsening morbidity. The pathophysiology of mental stress-induced myocardial ischaemia involves increased levels of neurotransmitters, as opposed to anatomical obstruction seen in conventional coronary artery disease. This results in a battery of tests (including invasive assessments) which yield normal results, deepening the patient’s psychological stress. There is therefore an increased expenditure on healthcare with little assurance of wellness. Detection of these conditions is poorer in developing countries due to limited capacity in appreciating mental health disorders, though over 70% of mental health disorders occur in these countries. Two young ladies with no comorbidities who presented with chest pain and palpitations are reported in this paper. Laboratory investigations and specific cardiology-based tests were normal, but a thorough family and social history revealed underlying mental stresses, corroborated by a mental state examination. A diagnosis of panic disorder was made and once managed, symptoms abated and quality of life improved. We seek to emphasise that mental health disorders are an important cause of cardiovascular symptoms among young adults and must be actively sought by physicians to reduce the associated morbidity, as conventional tests for ischaemia are not useful in their diagnosis. Mental state examination should be done routinely in all clinical assessments to identify patients with subtle signs and improve their clinical outcomes. There must be commitment to build capacity among nonpsychiatrists to reduce the treatment gap.
Chest pain is a common clinical symptom, especially in patients with sickle cell anemia. Owing to the vast differential diagnosis, investigation can be challenging. Typical chest pain (angina) is often attributed to obstructive coronary artery disease, with patients being referred for exercise stress tests for confirmation. Microvascular angina is emerging as a cause of significant morbidity worldwide, clinically identical to obstructive coronary artery disease. Clinical assessment and exercise stress testing often give the same results, making differentiation difficult. Coronary angiography however shows either normal coronary arteries or a nonobstructive lesion. An incomplete understanding of the etiopathogenesis of microvascular angina may result in missed diagnosis and suboptimal treatment in some cases. Coronary microvascular dysfunction plays a key role in this phenomenon, driven by chronic inflammation, thrombotic microangiopathy, and endothelial dysfunction. This article reports the case of a young man with chest pain, linking the highlights of the pathophysiology of microvascular disease in sickle cell anemia to microvascular angina.
Myocardial infarction with nonobstructive coronary arteries (MINOCA) is a significant cause of cardiovascular morbidity, especially among non-white women younger than 55 years. It is a working diagnosis that warrants further investigation due to its varied underlying pathophysiologic mechanisms. Investigations may be hampered by unavailability of testing modalities, cost, and the expertise to carry out the tests, as they are highly specialized. Clinical history is therefore important, especially in developing countries, to predict potential causes and institute empirical treatment without the luxury of tests. Some physicians are also unaware of this phenomenon and may dismiss symptoms as functional when a coronary angiogram shows nonobstructed coronary arteries, potentially resulting in patients suffering symptoms for longer and incurring extra cost. Most importantly, it leaves them at risk of major adverse cardiovascular events. This article presents a patient with atrial fibrillation who was diagnosed with MINOCA and highlights the diagnostic challenges in evaluating MINOCA.
Cushing syndrome could be a complication of long-term steroid use, resulting in a wide range of clinical presentations. Whereas some patients take medically prescribed doses of conventional medicines, including steroids for various ailments, others inadvertently consume unspecified doses by adulterating traditional medicines with these orthodox medications to increase their therapeutic appeal. Furthermore, some individuals with access to conventional medications may sell them in unlabelled packages as traditional medicines (TMs) to unsuspecting customers. This may lead to undesirable side effects and safety concerns. The case report highlights the problem of poorly regulated access to medications and makes suggestions to protect patrons' health of traditional medicines.
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