Journal of Clinical Case Reports

Aim: This work represents the experience of the department of radiodiagnostics of the Health Services Company of the Autonomous Province of Trento (APSS) which, in collaboration with the Human Resources Development Service, has shared and adopted the clinical competence system with the aim of supporting the choices on staff organization, maximizing the levers of development and the motivation of each one.

Methods: The general health situation always requires us to maintain constant levels of activity despite the limited economic and technological resources. To meet this need, our team considered it necessary to carry out a mapp of the skills of health professionals according to the criteria of the “clinical competence” system. To make a correct mapping, some parameters have been taken into consideration: the increase in the average age of doctors, the specialization of the supply network and the development of technologies.

Results: The application of the “clinical competence” system allowed us to set ourselves the goal of highlighting both the excellence and the areas that can be improved. The “clinical competence” system also gives us the opportunity to highlight the current critical issues or those that could appear in perspective. Everything has been conceived in a departmental/business logic (which coincides in our reality in Trentino).

Conclusion: Where strategies include the acquisition of people or the development of development paths, the departmental “Master Plan Human Resources” becomes a new strategic tool for negotiation with company management.

Objective: Study the presentation patterns and previous medical experience of patients with continuous or intermittent chronic pelvic pain.

Material and Methods: Presentation patterns of 113 patients with continuous or intermittent chronic pelvic pain were examined in an observational study. Details of history taken during previous consultations were assessed relative to a modified protocol based on the International Pelvic Pain Society assessment form.

Results: 80 and 33 patients presented with continuous or intermittent chronic pelvic pain respectively. There were no differences between the two groups regarding the combined prevalence of dysmenorrhoea with dyspareunia, bowel symptoms and pelvic tenderness. However, urinary symptoms were more common in the intermittent group and symptoms duration was longer in patients with continuous pain. History evaluation revealed 77 (68.1%), 91 (80.5%), 102 (90.3%), 18 (15.9%) and 98 (86.7%) patients were not interviewed before regarding detailed sexual or urinary history, painful defecation, pelvic infection or similar family history respectively. Furthermore, only 10 patients (8.8%) had bimanual pelvic examinations while menstruating. Further enquiry revealed personal and family history of autoimmune disorders in 58 patients (59.2%) with, and 3 (20.0%) without endometriosis, p=0.005. Hypothyroidism was the main disorder. Endometriosis was diagnosed in 98 (86.7%) patients, with no differences between the continuous or intermittent pain groups. 55 patients (48.7%) had previous surgery; 46 of them (83.5%) were performed for treatment of endometriosis. Combined dyspareunia, dysmenorrhoea and pelvic tenderness were highly associated with endometriosis which was diagnosed in 45 of 51 (88.2%) patients previously treated for irritable bowel syndrome.

Conclusion: Tailored protocols are necessary to guarantee proper interviewing of patients with chronic pelvic pain. Furthermore, combination of dysmenorrhoea, dyspareunia and pelvic tenderness during menstrual examination could be used for provisional diagnosis of endometriosis. Surgical interventions should be done in specialized centres for patients’ safety and to reduce the need for repeated operations.

The acute onset of chest pain, dyspnea, and decreased exercise tolerance is of significant concern. When this occurs in a teenage patient who was previously considered healthy requires further extensive evaluation. It is important to restrict any and all physical activity until a full cardiorespiratory evaluation has been completed along with laboratory evaluation. The aforementioned symptoms in an adolescent patient requires evaluation for congenital heart disease with thorough evaluation of the patient’s family history. An electrocardiogram may identify non-specific pathology that would guide and confirm the need for further diagnostic testing and evaluation. It is imperative to discuss and explain with the patient and parents what the concerns are, and the need for restricted physical activity over the course of the evaluation. Young athletes will have the desire to continue with their sport, but as the healthcare provider you must ensure that the patient and parents understand the danger that may be associated including sudden cardiac death.

Introduction: The physiologic changes of the respiratory system during pregnancy leave patients increasingly susceptible to viral respiratory disease. There are no documented cases of isolated rhinovirus in pregnancy causing respiratory distress requiring positive pressure ventilation.

Case: A 25-year-old primigravida at 28 weeks gestation reporting upper respiratory symptoms. She became tachycardic, tachypneic and hypoxic despite IV fluids and oxygen by nasal cannula. She was transferred to the ICU and transitioned to positive pressure ventilation via high-flow nasal cannula. Workup was notable only for rhinovirus. She improved following overnight observation in the ICU without need for endotracheal intubation.

Conclusion: We describe the first documented case of rhinovirus causing respiratory distress requiring positive pressure ventilation in a healthy pregnant patient, and the first to demonstrate the safe, effective use of high-flow nasal cannula in the critically-ill pregnant patient.

Atypical haemolytic uremic syndrome (aHUS) is a rare disease caused by chronic, uncontrolled activation of the alternative complement pathway that leads to thrombotic microangiopathy, haemolytic anaemia, acute renal impairment and thrombocytopenia. If left untreated, aHUS can progress into end stage renal disease and permanent renal impairment. Extrarenal manifestations have also been reported in the literature. Ocular involvement is usually rare in aHUS. This is a rare case report where a 13-year-old boy with aHUS presented with bilateral purtschers like retinopathy and sub retinal detachment in addition to renal impairment. The patient’s hematologic and renal parameters and ocular manifestation improved following appropriate therapy.

Pelagra was first described in Spain in 1795, with outbreaks in Italy and France until it became epidemic in the United States in the early 1900’s. Back then, nutritional deficiencies were common as a result of misinformation and famish until it was finally associated to maize, when eaten without being processed to make niacin available in the diet. Nowadays, the wide access to a considerable nutritional variety makes this disease oblivious to most of the medical staff in the current, daily practice. We describe a case of an eighty-five-year-old woman living in a rural isolated area in the southern Portugal, brought to the urgency services of our centre with itchy, edematous dermatological lesions in her face, hands and forearms for the last three days. When observed, the lesions were coarse, ulcerated with serohematic crusts in some areas, strictly delimited in areas of prolonged solar exposure, sparing the rest of the body. The history confirmed a poor intake of nutritional variety. Despite the poor contribution of analytical parameters for the diagnosis, as well as the unspecific dermo pathologic aspects, the clinical history favoured the hypothesis of Pellagra. The patient underwent niacin therapy and hydration with emollient, topic emulsions in the affected areas, with restricted improvement. With this case report we emphasize the importance of the nutritional details in a clinical history in patients with dermatological lesions, focusing as well in the distribution and aspect of those lesions. A careful history taking is essential to suspect such disease and, given its rarity, it is important to carefully consider all the differential diagnosis.

Objective: To study the relationship between persistent midluteal central endometrial echo versus polycystic ovaries and chromohysteroscopy and laparoscopy findings in infertile patients with regular menstruation.

Material and methods: 164 infertile patients with regular menstruation were investigated with ultrasound monitored cycles followed by chromohysteroscopy and laparoscopy. Persistent midluteal central endometrial echo was assessed against presence of polycystic ovaries, micropolyps and deep endometrial staining with methylene blue and presence of endometriosis diagnosed laparoscopically.

Results: 51 patients (31.1%) showed persistent central midluteal endometrial echo and 72 (43.9%) showed polycystic ovaries. During chromohysteroscopy 21 patients (12.8%) showed micropolyps and 26 (15.9%) showed deep endometrial staining with methylene blue. Moreover, 30/51 patients with central midluteal endometrial echo (58.8%) showed polycystic ovaries versus 42/113 patients (37.2%) with homogeneous endometrium, p=0.011. Furthermore, 18/51 patients (35.3%) with central endometrial echo showed dark endometrial discolouration with methylene blue versus 08/113 patients (7.1%) with homogenous endometrium, p<0.001. Similarly, 14/51 patients (27.5%) with central midluteal endometrial echo showed micropolyps versus 7/113 (6.2%) with homogeneous endometrium, p=0.001. Polycystic ovaries showed no significant association with either sign of chronic endometritis. During laparoscopy, 31/164 patients (18.9%) showed pelvic endometriosis. 14 of them (45.2%) developed deep endometrial discolouration with methylene blue versus 12/113 patients (9.0%) without endometriosis, p<0.001. Likewise, 21/31 patients with endometriosis (67.7%) had central midluteal endometrial echo versus 30/133 patients (22.6%) with no endometriosis, p<0.001. This association was maintained after excluding patients with chronic endometritis.

Conclusion: Persistent midluteal central endometrial echo might reflect chronic endometritis as it was significantly associated with deep endometrial discolouration with methylene blue and micropolyps. The significant association between endometriosis and midluteal central endometrial echo in cases with and without chronic endometritis indicated that endometriosis might affect the endometrium through more than one mechanism. Conversely, the association of polycystic ovaries with midluteal endometrial echo was independent of chronic endometritis.

Introduction: The risk of addiction in cancer patients with a relatively good prognosis is a challenge for modern medicine. As the number of therapies increases, so do patient survival and, consequently, the risk of inappropriate use of opioid drugs, especially the short-acting ones. The aim of the present study is to evaluate the decision to continue therapy with a short-acting fentanyl preparation and suggest possible alterations in the treatment plan of an addicted patient.

Methods and materials: The present study concerns a 49-year-old male patient with an advanced neuroendocrine tumour in the pre-sacral region. The tumour infiltrates the rectal wall and has formed metastases to the liver, lungs and bones. The patient is under the care of the Palliative Medicine Clinic due to the reported severe pain, assessed as 7-10 on the Numeric Rating Scale (NRS). In the course of the therapy with opioid analgesics, the patient has developed an addiction to the prescribed short-acting intranasal fentanyl preparation. The attempts to modify the treatment have not produced the desired effects due to aggravation of the symptoms and a lack of compliance. The patient remains pleased with the therapy and considers the prescribed fentanyl preparation to be the only effective drug. The research method includes the medical history and physical, an analysis of the patient’s medical record and a self-designed questionnaire to assess the degree of dependence on opioid drugs. The questionnaire consists of 19 questions divided into the major and minor criteria.

Conclusion: The analysis of the results of the survey results confirmed the patient’s dependence on opioid drugs. He gave positive answers to 16 out of 19 questions in the survey. The history and physical revealed that the patient was pleased with the instituted therapy as it allowed him to remain physically fit and maintain a high quality of life. Because of the advanced stage of the neoplastic process as well as the significantly increased pain, the improvement of life quality is of the utmost importance. Therefore, it seems justified to continue the intranasal fentanyl preparation therapy since it is both well- tolerated by the patient and able to produce a highly satisfactory analgesic effect.

Background: Some recent guidelines do not recommend the routine use of intra-aortic balloon pumping for patients with cardiogenic shock. Therefore, the use of Impella will further increase as an alternative to intra-aortic balloon pumping for many patients with cardiogenic shock and who are considered to be a high-risk group for percutaneous coronary intervention. However, some serious complications, such as renal failure and hemolysis, have been reported after the use of Impella. We here describe a rare case of acute renal failure with hemolysis caused by Impella.

Case presentation: A 66-year-old male patient presented with cardiogenic shock caused by ST-segment elevation myocardial infarction. We performed early revascularization supported by Impella because his vitals were unstable. The color of his urine turned blackish brown a few hours later, and he developed oliguria. On echocardiography, we found the pigtail catheter tip of Impella to be on the basal posterior wall; however, the device monitor showed no abnormal signs. Laboratory examination showed increased lactate dehydrogenase level, and we suspected acute renal failure with hemolysis caused by Impella. Therefore, we decided to remove the Impella device. Soon thereafter, the color of the patient’s urine became clear and his lactate dehydrogenase level improved. He received continuous renal replacement therapy 4 times, and his urinary output gradually increased, and his renal function eventually recovered completely.

Conclusion: We suspected that the main factor worsening the renal function of our patient was hemolysis caused by Impella. A routine echocardiography is useful for detection an improper location of Impella.

Background: Congenital hemangiomas are rare vascular tumors of infancy classified as rapidly involuting congenital hemangiomas (RICH) and non-involuting congenital hemangiomas. Intrathoracic hemangiomas are extremely rare and pulmonary hemangiomas specifically, are exceptional and usually solitary lesions.

Case presentation: We present in this report the special case of a newborn with a triad of a congenital pulmonary hemangioma, cutaneous RICH and an atrial septal defect (ASD).

Conclusion: This is, to our knowledge, a first case of a triad of congenital pulmonary hemangioma, along with cutaneous RICH and an ASD that can be particularly important in clinical management given that the volume overload associated with an ASD, when added to the lung pathology of pulmonary hemangiomas, can lead long-term to possible pulmonary hypertension.