Pneumomediastinum is an uncommon complication of sporting activity. The case of a young asthmatic surf lifesaver is reported in which several factors are thought to have been involved in the aetiology of his condition. Treatment was expectant and a full recovery was made over a short period. This is the first reported case of pneumomediastinum occurring following training for a surfbelt race. (BrJ7 Sports Med 1996;30:359-360) The patient was treated expectantly and the management of his asthma was reviewed.Three days following the initial consultation he complained of left sided chest pain on very deep inspiration and the surgical emphysema had clinically resolved. Chest x ray two weeks later was normal. DiscussionPneumomediastinum is a relatively rare condition which has been associated with mechanical ventilation, childbirth, marked vomiting and coughing,' marijuana smoking,2 asthma, closed tracheal injury, and anorexia nervosa. In relation to athletic activity it has been described following swimming,"7 tennis,' weight lifting,"4 football,57 mountain climbing,6 rugby training,8 fast bowling in cricket,9 scuba diving, 112 and kendo. "In a general population study the mean age of patients with spontaneous pneumomediastinum was 18.8 years and 84% were male. The most common symptoms on initial presentation are chest pain (88%), dyspnoea (60%), and neck pain (48%), the most frequent physical sign being subcutaneous emphysema (60%) most commonly found in the neck (40%).' Auscultation may reveal a crunching sound during systole-Hamman sign-which was reported in 52% of cases in one series.'4 Should sufficient air accumulate in the mediastinum the pleura can rupture, resulting in an associated pneumothorax. Particularly in cases of traumatic aetiology, oesophageal rupture (Boerhaave syndrome) should be excluded. Treatment of non-traumatic cases is expectant and does not usually require hospital admission. Resolution occurs rapidly and complications such as pneumothorax and airway compromise are rare.4 15Cases described in the athletic population occurred in young males,4 5 7-9 most presenting with anterior chest pain, and were associated with straining which may have involved a Valsalva manoeuvre489 or a direct blow to the chest. 5 In no case so far reported has asthma been a potential aetiological factor.The patient in this case is again a young male who presented with a sore throat, a presentation previously reported.8 His history indicates that the onset of pneumopericardium was related to severe exertion possibly associated with Valsalva manoeuvres, breath holding, underwater swimming, and abdominal compression by the surf belt. Chronic but apparently well controlled asthma may well have been a factor since, while the patient was asymptomatic at the time of his swim, subclinical airways obstruction and associated alveolar distension may well have been present. The patient's usual asthma prophylactic medication was not used before exertion. 1996;30:360-362 It is conceivable that the onset of pneumom...
The coronavirus disease 2019 (COVID-19) is characterized by flu-like symptoms or complications related to pneumonia and acute respiratory distress syndrome. Later in the disease course, clinically significant thrombotic events, both venous and arterial, are being recognized. Our case describes ST elevation myocardial infarction (STEMI) as a complication of COVID-19. CASE PRESENTATION: A 38-year-old male with no medical history and non-smoker presented with 10 days of fever, cough, malaise, myalgia, and exertional dyspnea. He denied chest pain. He had completed a five-day course of azithromycin and steroids. No personal or family history of clotting disorders or heart disease. Exam revealed oxygen saturation of 89% on room air with bilateral crepitations. Chest x-ray showed bilateral patchy parenchymal airspace disease. Electrocardiogram (EKG) showed sinus tachycardia without ischemic changes. Labs showed C-reactive protein 179 mg/L and D-dimer 0.64 ug/mL. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by polymerase chain reaction assay was positive. He was started on ceftriaxone, doxycycline, hydroxychloroquine, enoxaparin, and methylprednisolone. After 5 days, he was discharged on prophylactic apixaban. He returned 1 day later with substernal chest pain. EKG showed ST elevation in the inferior leads. Troponin T was 3.74 ng/mL, D-dimer 0.75 ug/mL, and coagulation profile was normal. Emergent coronary angiography revealed 100% occlusion of mid-right coronary artery and right posterolateral branch requiring extensive thrombectomy and placement of drug eluting stents. He was started on aspirin, ticagrelor, eptifibatide, high intensity statin, and metoprolol. Echocardiography revealed severe basal to mid-inferior and posterior wall hypokinesis with left ventricular ejection fraction of 40%. He was discharged on ticagrelor, apixaban, atorvastatin and metoprolol. Antiphospholipid antibody panel testing results returned normal.
Background NASBO recommends Computed Topography (CT) over plain abdominal X-ray (AXR) for the investigation of bowel obstruction (BO). AXR is routinely used within PAT for investigation of BO which may be exposing patients to unnecessary radiation and adding unnecessary cost to the service. Method A retrospective audit collected data on patients with CT confirmed BO between July 2019 and February 2020. This looked at the percentage of patients who had both CT and AXR to investigate BO. The cost of these AXRs and the percentage of these AXRs that were normal were also calculated. Results A search identified 141 patients with CT proven BO. 81/141(57.4%) patients had both AXR and CT as a part of their initial investigations. Of those patients 26/81(32.1%) had no AXR features suggestive of BO. Only 12/81(14.8%) of those patients had serial AXRs following initial imaging. The cost for one AXR is £34.15 which means £2766.15 was spent on potentially unnecessary AXRs within this period. Conclusions PAT is performing potentially unnecessary AXRs which is exposing patients to unnecessary radiation and costing the trust. Plain AXRs do not rule out BO. We have recommended an investigation flowchart to PAT A&E departments to reduce unnecessary AXRs being performed.
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