Patient: Male, 46-year-old Final Diagnosis: Cholecystitis Symptoms: Chest pain Medication: — Clinical Procedure: — Specialty: General and Internal Medicine Objective: Unusual clinical course Background: Cope’s sign is the association of bradycardia with symptoms of acute cholecystitis, which can occur due to a vagal cardiobiliary reflex. The clinical and electrocardiographic changes of bradycardia or complete heart block can mimic the presentation of acute coronary syndrome. This report highlights the unique possibility that bradycardia in patients with abdominal pain and gallstones can be due to this reflex. Case Report: A 46-year-old obese man with hyperlipidemia and gallstones presented with chest pain suggestive of cardiac ischemia. The initial electrocardiography (EKG) was normal, although the patient subsequently developed bradycardia and a 2 nd -degree atrioventricular (AV) block. The results of further cardiothoracic investigations (including echocardiography and pharmacologic stress testing) were normal. An ultrasound of the abdomen revealed acute cholecystitis. After he underwent a laparoscopic cholecystectomy, the chest pain resolved completely, and the EKG reverted to its normal sinus rhythm. Conclusions: Acute cholecystitis rarely presents with cardiac chest pain and EKG changes due to triggering of the vagal cardiobiliary reflex. Given this atypical presentation, patients often undergo invasive cardiac procedures in search of a nonexistent cardiac etiology coupled with the possibility of a missed diagnosis of cholecystitis. When clinicians consider a diagnosis of acute coronary syndrome in patients with bradycardia, T-wave inversion, and ST-segment elevation (especially in the inferior leads), they should add the possibility of intra-abdominal pathologies (including cholecystitis) in the differential diagnosis.

Prostate cancer most commonly metastasizes to bone, lymph nodes, lungs, or liver, but rarely spreads to the large intestine. This case highlights a rare case of castrate-resistant prostate cancer (CRPC) that spread locally to the large intestine and rectum, significant enough to cause bowel obstruction. Metastatic prostate carcinomas are considered an infrequent cause of bowel obstruction.

Immunotherapy is a biological therapy that helps the body's immune system to fight against cancer cells. The Food and Drug Administration (FDA) approved the first immune checkpoint inhibitor in 2011. Since 2011, many immune checkpoint inhibitors have been approved. Programmed cell death 1 (PD-1) inhibitors are now commonly used in multiple malignancies due to their remarkable response. Thus, immune-related adverse events are now coming into the limelight due to the increasing use of PD-1 inhibitors. Here, we present a case of a 54-year-old female with non-small cell lung cancers (NSCLC) treated with pembrolizumab and later presented with severe neurotoxicity.

Background: Non-alcoholic liver disease causes liver damage and influences the insulin production, metabolic and inflammatory pathways and renal sufficiency. Aim: To find an association of fatty liver, metabolic syndrome and subclinical inflammation on mild renal inadequacy. Study design: Comparative analytical study Place and duration of study: Department of Medicine, Bolan Medical College Quetta from 1st January 2020 to 30th June 2021. Methodology: One hundred and twenty patients were enrolled. They were divided in two groups; 60 controls and 60 non-alcoholic fatty liver disease patients age between 30-55 years of age included. Their demographic, ultrasonography, anthropometric measurements and biochemical details were recorded. Results: There were 34 men out of 60 having NA fatty liver with a mean age of 45±5.8 years. Mild renal inadequacy was seen in 21, metabolic syndrome in 27, hypertension in 18 and diabetes in 8 of non-alcoholic fatty liver patients with a mean raised CRP as 1.5±0.8mg/L. Conclusion: Non-alcoholic fatty liver presence in addition to metabolic syndrome and subclinical inflammation effect on mild renal inadequacy Key words: Fatty liver, Metabolic syndrome, Subclinical inflammation, Mild renal inadequacy

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