Hypertension has been shown to have long-term cardiovascular effects if left untreated. Hypertension also has been shown to affect women during pregnancy, which can be detrimental not only to the patient but also to the fetus. Early identification and treatment are paramount to prevent adverse outcomes. This article details the epidemiology, clinical presentation, diagnosis, and treatment of essential hypertension in women, gestational hypertension, preeclampsia, and eclampsia.
Hypertension, Pregnancy-Induced , Hypertension , Pre-Eclampsia , Pregnancy , Female , Humans , Pre-Eclampsia/diagnosis , Pre-Eclampsia/epidemiology , Pre-Eclampsia/therapy , Hypertension, Pregnancy-Induced/diagnosis , Hypertension, Pregnancy-Induced/epidemiology , Hypertension, Pregnancy-Induced/therapy
Paroxysmal atrioventricular block (PAVB) is characterized by a sudden and unanticipated repetitive block of atrial impulses to the ventricles. It is often triggered by supraventricular and ventricular ectopic beats in patients with diseased His-Purkinje system. We present the case of a 69-year-old woman with a history of fascicular block who was admitted with gastrointestinal bleeding. Her hospital course was complicated by cardiac arrest. At the time of the loss of consciousness, telemetry tracings showed sudden onset high-grade second-degree atrioventricular (AV) block with a delayed escape rhythm resulting in a prolonged pause. Adult cardiac life support was necessary along with transvenous pacing until she ultimately underwent the placement of a permanent pacemaker. Thorough evaluation of electrocardiograms (EKGs) and telemetry allowed for accurate diagnoses and appropriate treatment of cardiac arrest secondary to paroxysmal AV block.
Objective: To perform a quality assurance study assessing if hypo- and hyperthyroidism are appropriately screened for in patients with resistant hypertension.Design: Data was collected from patients diagnosed with resistant hypertension, defined as being on four or more different classes of anti-hypertensive medications. These patients were filtered to determine if thyroid stimulating hormone (TSH) measurement occurred within 90 days of the addition of a fourth medication class.Setting: Two internal medicine residency clinics in Pittsburgh, PA.Participants: Patients were selected who had a diagnosis of hypertension and were seen in clinic between January 1, 2018 and December 23, 2020.Methods: A single center retrospective review was performed.Results: A total of 1,125 patients were identified as having resistant hypertension. Of these, only 74 patients were found to have a TSH measurement taken within 90 days of having a fourth medication class prescribed. Seven TSH values were found to be abnormal with one patient being diagnosed with hyperthyroidism, demonstrating a screening rate of 6.6%. There were statistically significant differences in age, body mass index, and diastolic blood pressure in those screened versus not.Conclusions: Thyroid disease is under-screened as an etiology for resistant hypertension, particularly given the ease of diagnosis and reversibility of these conditions.
Hypertension , Hyperthyroidism , Thyroid Diseases , Humans , Hypertension/diagnosis , Hypertension/drug therapy , Hyperthyroidism/complications , Hyperthyroidism/diagnosis , Thyrotropin
High-risk patients over the age of 65, who had chronic medical conditions, and had not yet had a primary care visit within 2020 were identified. A subgroup of patients participated in a survey to assess social determinants of health (SDOH) in the setting of a pandemic. Outcomes of those who participated in the survey, and those who did not participate were compared. Notably, those who were surveyed and lived within zip codes with low socioeconomic status had significantly decreased emergency department visits, which we defined as a discharge from the emergency department without hospitalization, as compared to those who did not receive outreach. Rates of inpatient hospitalization did not differ significantly. These findings suggest that patient outreach to evaluate SDOH during a pandemic leads to more appropriate emergency department and hospital resource utilization. This finding is particularly impactful given the current pandemic, which may place a strain on emergency department, and healthcare resources.
Currently, the world has found itself in a global pandemic with coronavirus. At its start, to limit the spread of this virus, countries, states, and counties have implemented stay-at-home orders and shutdowns. These shutdowns had great impacts on people's well-being and exacerbated social determinants of health. This project aims to identify patient social determinants of health and their associations during the COVID-19 pandemic via telemedicine. METHODS: A total of 104 patients were surveyed within Pittsburgh, Pennsylvania, who had not been seen for at least 4 weeks before March 23, 2020 and who did not have a scheduled visit within 4 weeks of the initial survey. Based on a patient's specific response, resources were then allocated to them. RESULTS: Most patients surveyed identified at least 1 social determinant of health, the most common being financial issues (27%), mental health issues (26%), and access to food (19%). A statistically significant relationship was found between patients who identified finances with access to food, access to medication with struggling to care for themselves or others, and physical wellness with mental health. Lastly, an association was found between those who did not identify any difficulties and wanting more information. CONCLUSIONS: By identifying needed barriers via telemedicine, we can properly allocate resources to those who need it the most and hope to decrease the potential long-term effects of this current pandemic.
Identifying social determinants of health can help diagnose certain nutritional deficiencies. By overcoming these barriers, we can prevent future hospitalizations and better public health. We present a unique case where a 46-year-old man presents with bilateral lower extremity swelling secondary to vitamin C deficiency. Throughout history taking, his social determinants of health were identified and he was diagnosed with scurvy from the suspected poor nutritional intake. His poor nutritional intake could have resulted from a lack of financial stability and a harsh home environment. This case is evidence that social determinants of health can directly impact a patient's well-being, and as physicians, we need to identify them to provide the most resources we can to help improve patient care. This in turn can decrease unnecessary emergency room visits and hospitalizations.
The use of ultrasound enhancing agents (UEA) during echocardiography helps to optimize visualization in technically difficult studies, with improved left ventricular opacification and endocardial border definition. The use of these agents may often unveil critical data that drastically alter clinical decision making. Despite the potential clinical benefits of UEA and known safety data, clinicians are still sometimes reluctant to take the time to use UEAs in unstable patients. Herein, we demonstrate a challenging case of a patient with late presentation myocardial infarction, complicated with cardiogenic shock and pseudoaneurysm formation that was not observed in non-contrast images, emblematically demonstrating the value of UEA in selected patients.
In the era of a pandemic, the utilization of telemedicine is growing at a rapid speed. This new and necessary adaption in medicine is a threat to the basics of medicine which include the physical exam. A 72-year-old woman presents for a 1-week history of cervical neck discomfort. The patient was found to be febrile with initial physical exam nonrevealing due to patient preference of not taking off hospital gown. After blood cultures grew group A beta-hemolytic streptococcus and a computed tomography scan of the abdomen and pelvis with contrast demonstrated subtle bilateral renal hypodensities suggesting possible septic emboli, a more thorough physical exam was sought out which revealed a large rodent ulcer which the patient had been hiding from her family for 2 years. Transthoracic echocardiography was done which demonstrated a vegetation on the mitral valve confirming the diagnosis of endocarditis. The source of infection was the ulcer which was biopsied and found to be basal cell carcinoma. We present a unique case of endocarditis that was reliant on the physical exam to reveal the source of infection which was a rodent basal cell carcinoma ulcer. This case reminds physicians that at the forefront of telemedicine, the physical exam should not be forgotten.
